V 

<6 



V 



EPITOME 



OF 



SKIN DISEASES, 



WITH FORMULAE, 



FOR STUDENTS AND PRACTITIONERS. 



BY 

TILBURY FOX, M.D., F.E.C.P., 

PHYSICIAN TO THE DEPARTMENT FOR SKIN DISEASES IN UNIVERSITY 

COLLEGE HOSPITAL, 

AUTHOR OP VARIOUS WORKS ON SKIN DISEASES, ETC. 

AND 

T. C. FOX, M.B., B.A. (Cantab.), 

t V PHYSICIAN TO SAINT GEORGE'S AND SAINT JAMES'S DISPENSARY. 

; 

SECOND AMERICAN EDITION, 

ENLARGED AND REVISED BY THE AUTHORS 




o. 331.LJ0 



PHILADELPHIA: 

HENRY O . LEA. 

1879. 






Entered according to the Act of Congress, in the year 1879, by 

HENRY C. LEA, 

iu the Office of the Librarian of Congress. All rights reserved. 



COLLINS, PRINTER 



AMERICAN PUBLISHER'S NOTE. 



In printing this work from the MS. kindly furnished 
by the Authors, the press has been supervised by a com- 
petent professional gentleman, to secure the necessary 
accuracy of the text ; and there has been introduced on 
page 50 the Classification of Dermal Diseases adopted 
by the American Dermatological Association. 

Philadelphia, March, 1879. 



PREFACE TO THE SECOND AMERICAN EDITION. 



In preparing this edition of our "Epitome" for pub- 
lication in the United States, we have increased the matter 
to about three times its original amount. The kindly 
appreciation manifested for the work by the American 
profession has stimulated us to spare no pains in render- 
ing it more worthy of their approbation, and in its en- 
larged form we believe that it will be found of enhanced 
value. About two-thirds of the work is newly written, 
and we may direct attention particularly to the section 
regarding the Pathology of the Skin, which has been 
entirely recast, and now contains a concise account of 
all the important changes taking place in the dermal 
textures in disease. The clinical descriptions of diseases 
also have been amplified and occasionally remodelled. 
Lastly, we may say that in adding material to the book 
we have selected such as bears on the practical side of 

1* 



VI PREFACE TO SECOND AMERICAN EDITION. 

Dermatology, to the exclusion of that which is as yet 
hypothetical or merely of interest to the curious student. 
The favorable reception accorded to the work on both 
sides of the Atlantic would seem to show that it has 
realized the object with which it was prepared — to afford 
assistance to the student in his early study of derma- 
tology, and to serve as a manual for ready reference by 
the practitioner in his daily practice. For this latter 
purpose it has been specially adapted, by means of the 
references made in the sections on treatment to the 
formulae at the end. 

TILBURY FOX, 
THOMAS COLCOTT FOX. 

14 Harley Street, London, W., 
January 1, 1879. 



CO 1ST TENTS. 



PART I. 

PAQB 

General Observations on Skin Diseases . . 13 

SECTION I. 
The Mode of Observing Skin Diseases : — 

1. As to the General Character of Skin Eruptions . . 13 

2. As to the Mode of Examining Skin Diseases . . 14 

3. As regards Complications ...... 17 

4. Modifications of Eruptions ...... 18 

SECTION II. 
The Pathology of the Skin : — 

1. Elementary" Lesions ....... 21 

2. Secondary Changes ....... 32 

3. General Observations on the Pathology of the Skin . 34 

SECTION III. 

Classification or Diagnostic Chart of Skin Diseases : — 

1. Eruptions occurring in Connection with the Acute 



Specific or Zymotic Diseases . 

2. Eruptions connected with Diathetic Conditions 

3. Local Inflammations ..... 

4. Hypertrophic and Atrophic Diseases . 

5. New Formations 

6. Hemorrhagic Disorders .... 



44 
45 
45 
46 
46 
46 



Vlll CONTENTS. 



7. Neuroses 

8. Pigmentary Alterations ... 

9. Parasitic Diseases .... 

10. Diseases of the Glands and Appendages . 

11. Peculiarities of Skin Diseases in the United States 

12. Classification and Nomenclature of American Derma- 

tological Association 50 



PAGE 

46 
46 
47 

47 
48 



SECTION IV. 
The Causes of Skin Diseases 54 

SECTION V. 
Diagnosis 60 

SECTION VI. 
General Principles of Treatment . . . .62 

PART II. 

The Description and Treatment of Skin Diseases. 

Acne 69 

Alopecia, or Baldness 75 

Anthrax, or Carbuncle .....<. 76 
Area, see Alopecia. 

Atrophia Cutis .77 

Bakers' Itch 79 

Baldness, see Alopecia. 

Barbadoes Leg, see Bucnemia. 

Boils, see Furunculi. 

Bricklayers' Itch ........ 79 

Bromide Eruption 79 

Bucnemia Tropica, see Elephantiasis Arabum. 

Bug-eruption ......... 81 

Cacotrophia folliculorum ...... 81 

Cancer, see Epithelioma and Rodent Ulcer. 
Carbuncle, see Anthrax. 
Chloasma, see Tinea versicolor. 



CONTENTS. 



IX 



Comedones 

Condylomata . 

Contagions Impetigo 

Dermatitis exfoliativa 

Dysidrosis 

Ecthyma 

Eczema . 

Elephantiasis Arabum 

Elephantiasis Graecorum 

Elephantiasis Telangiectodes . 

Epithelioma, or Epithelial Cancer 

Erythema .... 

Favus, see Tinea favosa. 

Fibroma ..... 

Fish-Skin Disease, see Ichthyosis. 

Follicular Hyperemia 

Fungi, see Tinea. 

Furunculus .... 

Grocers' Itch .... 

Guinea-worm Disease 

Gutta rosacea, see Acne rosacea. 

Herpes . 

Hydroa . 

Hydradenitis 

Hyperidrosis . 

Ichthyosis 

Impetigo 

Impetigo contagiosa 

Intertrigo, see Erythema. 

Iodide of Potassium Rash 

Itch, see Scabies. 

Keloid 

Kerion, see Tinea kerion. 

Lepra 

Leucoderma .... 
Lichen ..... 
Lichen urticatus, see Urticaria. 
Lupus ..... 
Maculae ..... 
Medicinal rashes 



PAGE 

82 

82 

83 

83 

83 

85 

86 

97 

103 

105 

106 

106 

110 

110 

111 
112 
112 

113 
117 
121 
122 
123 
126 
126 

129 

130 

130 
130 
132 

135 
139 
139 



CONTENTS. 

PAGE 

Miliaria 140 

Molhiscum contagiosum . . . . . . . 141 

Morplicea 143 

Nails . . . .145 

Pediculi, see Phthiriasis. 

Peliosis Rheumatica, see Purpura. 

Pemphigus ......... 147 

Plitliiriasis ......... 149 

Pigment Increase ........ 150 

Pityriasis . . 153 

Porrigo .......... 154 

Prickly Heat, or Lichen Tropicus 154 

Prurigo .......... 155 

Pruritus, or Itching . . . . . . . 156 

Psoriasis . . . . . . . . . 158 

Purpura .......... 1G4 

Ringworm, see Tinea. 

Rodent cancer . . . . . . . . .165 

Roseola 166 

Rupia . 167 

Scabies, or Itch ........ 167 

Scabies in private practice . . . . . .169 

Scleroderma . . . . . . . . .170 

Scrofuloderma . . . . . . . .173 

Seborrhoea ......... 174 

Strophulus, or Red Gum 175 

Sudamina ......... 176 

Sycosis 176 

Syphilis of the Skin 178 

Tinea . .184 

Trichorexia Nodosum, or Trichoclasis .... 189 
Urticaria, or Nettle-rash ....... 190 

Vitiligo . . . .192 

Vitiligoidea 193 

Xanthelasma 193 

Xanthelasmoidea ....... 196 

Xeroderma, see Ichthyosis. 
Zoster, see Herpes. 



CONTENTS. XI 

PART III. 

Cutaneous Pharmacopoeia. 

PARE 

Baths 199 

Fumigation ......... 199 

Caustics 200 

Astringents ......... 201 

Sedatives . 202 

Absorbent Powders 205 

Stimulants and Absorbents ...... 205 

Plasters . . 208 

Mixtures 208 

Pills 210 

Remedies for Scabies and Phtliiriasis .... 211 

Remedies for Vegetable Parasitic Diseases . . . 212 

Diet in Skin Diseases 214 



EPITOME OF SKIN DISEASES. 



PAET I. 

THE GENERAL PRINCIPLES OF CUTANEOUS 

MEDICINE. 



SECTION I. 

THE MODE OF OBSERVING SKIN DISEASES. 

In order to pursue the clinical study, and to prosecute the 
treatment, of maladies of the skin with the best chances ot 
success, attention should be primarily directed to one or two 
important considerations ; relating, on the one hand, to the 
general character of cutaneous changes, and, on the other, to 
the mode of examining patients attacked by these diseases, 
as well as to some general facts concerning the complications 
and modifications of the disorders themselves. 

First. As to the General Character of Skin Diseases 

Really, there is nothing specialin the pathological changes 
occurring in the textures in these disorders. When the 
student approaches the study of cutaneous maladies, he is 
apt to imagine that he is about to encounter a new set of 
pathological phenomena, different from those with which he 
has been made acquainted in morbid alterations in other 
parts of the body, which in reality is not true. Recent 
researches in cutaneous pathology have cleared the way to a 
more correct knowledge of the changes taking place in the 
skin in disease, and, as a consequence, it is becoming more 
2 



14 MODE OF OBSERVING SKIN DISEASES. 

and more apparent that these morbid processes are identical 
with those occurring elsewhere in the body ; whilst a propo- 
sition to group skin diseases according to their pathological 
affinities, upon a plan like to that on which other maladies 
are classified, is now seriously entertained. It is a noteworthy 
and satisfactory circumstance that the student of to-day, who 
is compelled to acquire pathological knowledge over a wide 
field, is beginning to discover that his study of skin diseases 
is rendered comparatively easy, because of the complete simi- 
larity which has now been demonstrated to exist between 
the facts of general and of skin pathology. The reader does 
not find himself dealing with strange topics or data, but 
recognizes familiar appearances, changes, and causes in 
morbid action, when he turns from his study of the diseased 
states of other organs to deal especially with those of the in- 
tegument in its several parts. It is all-important, then, to 
understand that there is nothing essentially peculiar in the 
principles of cutaneous pathology. 

The misconception which has so long prevailed on this 
point, it is not difficult to account for. The student has been 
bewildered and often misled by the prominence given to the 
mere external form and aspect of eruptions, whilst the multi- 
tudinous names, too, which have from time to time been 
coined with great prolixity as designations for the infinite 
varieties of these external appearances, have been so unlike 
those applied to diseased states in other parts of the body, 
that they have materially supported the belief in an essential 
difference and peculiarity in the nature of cutaneous dis- 
orders. 

Secondly. As to the Mode of Examining Shin Dis- 
eases — In examining eruptions with the object of ascertain- 
ing their specific characters, error is frequently committed in 
attempting to decide upon these characters from a too partial 
or superficial examination of the phenomena they disclose to 



MODE OP OBSERVING SKIN DISEASES. 15 

the senses of the practitioner, and without due inquiry into their 
antecedents. Many persons are wont to content themselves 
with making a diagnosis at sight, judging from mere aspect 
alone. In many cases, without doubt, the nature of the dis- 
ease under scrutiny can be correctly made out at once by an 
expert, simply from inspection, even when that is of a very 
partial kind, wherever the eruption assumes from the out- 
set, and preserves throughout its course, its typical charac- 
ters. But in other instances, on the contrary, it is difficult 
or impossible to make an accurate diagnosis without careful 
inspection of many parts of the disease in several localities in 
a given patient, and an inquiry into the previous history of its 
course. For many skin diseases have definite stages, and 
at the time of observation these may vary considerably in 
different parts of the body. The typical phenomena of a given 
eruption may be only in progress of development here, or be 
lost there, or modified by scratching in another locality. 
But an examination of the disease in several regions of the 
body will often disclose the existence of its earlier characters 
as well as the later changes, by means of which the general 
nature of the disease may be determined. Typical features 
may be discovered, in some cases, in a region of the body 
which, perhaps, comes last under inspection, when they have 
been absent in several other parts examined. But sometimes 
it is necessary to go carefully into the history of the case to 
discover the evidence of the existence of diagnostic features 
which formerly existed, though lost at the time of actual 
observation by the practitioner. Further, in reference to 
the necessity of a thorough examin'ation of patients suffer- 
ing from cutaneous troubles for the purpose of diagnosis, it 
is important to add that parts, or stages of different mala- 
dies often resemble one another, and may convey a very 
imperfect picture of a disorder. To avoid error then the 
diagnosis should be based upon a careful estimation of the 
phenomena or features presented by any given disease as a 



16 MODE OP OBSERVING SKIN DISEASES. 

whole, and not upon the data afforded by any particular por- 
tion of the history, or distribution, of that disease. 

The foregoing observations may be summed up in two car- 
dinal principles, or to put the matter in another form, we may 
say, from what has been mentioned about the mode of ex- 
amination of cases of skin disease, that there are two im- 
portant rules which should be observed in attempting to 
make a proper diagnosis of a disease of the skin : — 

The first rule is this : — 

All diseased places, or as many as possible, should be care- 
fully examined, and not one only, or one here and there: for 
the simple reason that the eruption may be at very different 
stages of development, and therefore present diverse aspects, 
in different localities upon the same patient. 

The second rule is as follows : — 

Where in any given case the earlier stages are not present 
so as to be recognizable, careful inquiry should be made 
by interrogation of the patient, as to the changes that have 
occurred before the disease came under observation, with the 
view of determining its nature. 

The object of the examination prescribed by the first of 
these two rules is to trace out the origin and course of the dis- 
ease, and to link together the various stages into a complete 
history which will correspond in its clinical features with an 
authoritative standard description of the disease, whatever it 
may be. During this examination special attention should be 
directed to the character of the newest developments of the 
eruption with the intention of determining the " initial or 
elementary lesion," as it is called (to be presently referred 
to), or if there really be no new spots of eruption, the ob- 
server should carefully note the features presented by the 
extending edges of patches, which always constitute the most 
recently developed parts of the disease, and which, therefore, 
often portray the primary lesion. Complications are also 
more likely to be recognized by attention to this point. 



MODE OF OBSERVING SKIN DISEASES. It 

The use of the second of the two rules has been cursorily 
referred to in a previous paragraph, but requires further dis- 
cussion. 

Very frequently no fresh developments of the eruption 
are taking place at the time of observation, and no exten- 
sion of a given patch has occurred for some time. The 
malady has in fact become chronic and indolent, and more- 
over has lost its typical features oftentimes. The only way 
of making a diagnosis under these circumstances is by ob- 
serving this second rule. For example, eczema is charac- 
terized mainly by a peculiar discharge, but the discharging 
stage, frequently, has passed before the case comes under 
medical observation, and the affection may present a dry 
and scaly appearance and be readily mistaken for psoriasis — 
a not infrequent error. Again, a disease essentially papular 
may have become inflamed and encrusted, and its true nature 
may therefore be overlooked, unless its history be carefully 
inquired into. 

By the observance of these two rules the student ascer- 
tains what is the elementary lesion, as well as the cha- 
racters of the several stages of different eruptions; and he 
should form with these materials a picture of the malady and 
so make an accurate diagnosis, just as the child with his dis- 
sected puzzle puts together the animal or landscape bit by 
bit to form the desired whole. 

Thirdly. As regards Complications. — It should never 
be forgotten that two or more eruptions may occur together. 
When this is the case the different features of the concurring 
diseases will be mingled in varying proportion, and the ob- 
server will find himself dealing with characters and pheno- 
mena which, theoretically at least, he has learned are exhibited 
by different maladies. Examples of such commingling are to 
be found in the common coexistence in the same patient of 
urticaria and scabies, of syphilitic rash and chloasma, lichen 

9* 



18 MODE OP OBSERVING SKIN DISEASES. 

and urticaria, of ecthyma and scabies, of purpura and urti- 
caria, of eczema and scabies or fur •an cuius, and so on. The 
possibility of the coexistence of two diseases should never 
be lost sight of. Multiformity of eruption is, however, by 
no means sufficient evidence, although it is suggestive, of the 
coexistence of two or more distinct diseases, because certain 
uncomplicated diseases of the skin possess this feature. 
Practically it may be said, however, that there are only three 
diseases, which are essentially multiform in eruptive charac- 
ter. They are scabies, eczema, and syphilis. Supposing, 
therefore, that scabies, eczema, and syphilitic disease can be 
said to be absent, multiformity of eruption usually indicates 
the coexistence of two or more distinct eruptions. 

Fourthly. As regards Modifications of Eruptions 

There are many influences which modify the aspect and the 
general character and behavior of skin diseases, which should 
be taken into account in dealing with their treatment. It 
is not only necessary that the physician should recognize any 
particular kind and form of skin eruption, but that he should 
appreciate the part played by a number of concomitant con- 
ditions in each individual, which modify the character and the 
duration of the particular disease present. There are various 
diatheses, special states of the blood, of nerve influence, and 
of tissue change, which specially tend to induce an unusual 
amount of inflammatory action, or favor undue cell activity 
or pus formation, or disorder of sensation, and the like, to 
which due consideration must be given. The evil influences 
of such conditions must be dealt with, so as to pave the way 
for the due action of curative measures directed against the 
disease more directly. 

A few useful particulars or hints may not inappropriately 
be given here. Diseases of the skin are made to spread or 
take on an inflammatory character, and changes in the skin 
are exaggerated, by exposure to irritating agencies, such as 



MODE OP OBSERVING SKIN DISEASES. 19 

heat, cold, scratching, and by the contact of acrid substances 
of all kinds, as the handling of lime, sugar, and soda respec- 
tively, by bricklayers, grocers, and washerwomen. So, too, 
an inflammatory aspect is given to eruptions by acridities in 
the blood, as in gouty or rheumatic subjects, in dyspeptics ; 
and in those in whom the bile acids, sugar, or retained effete 
matters are present in undue amount in the blood. Erup- 
tions in strumous subjects are attended by an amount of pus 
formation which is unusual in non-strumous subjects. Undue 
chronicity is occasioned, oftentimes, by the existence of ner- 
vous or general debility : for nature then lacks the normal 
recuperative power which it always tries to exert in aid of 
the cure of disease. 

The questions of age, sex, occupation, mode of life, and 
the general medical history of the patient have to be con- 
sidered, and will be incidentally referred to in other places. 
Attention to the four indications already discussed will, 
however, be found of essential importance in the successful 
study, or in determining the treatment, of a skin disease. It 
may be observed, however, as regards age, that one essen- 
tial difference between the cutaneous diseases of the young, 
as compared with those occurring in the middle-aged and 
old, consists in the fact that the former are often the result 
of imperfect digestion and assimilation, whereas the latter 
are induced by mal-influences connected with the habits and 
occupations and wear and tear of adult life, and degeneration 
of structure in the old, and are modified by a number of 
functional and organic diseases of internal organs, which are 
conspicuous by their absence in the young. The modifying 
influence exerted upon skin troubles by the strumous diathesis, 
however, is infinitely more common in the young. 



20 THE PATHOLOGY OF THE SKIN. 



SECTION II. 

THE PATHOLOGY OF THE SKIN. 

Recent research in the field of dermatological pathology 
has advanced this branch of medical science to a reputable 
position ; and dermatologists are beginning to describe with 
no little accuracy, and with an increasing general agreement 
amongst themselves, the minute tissue changes that go on 
in the various disorders of the skin, and to define with more 
approach to the truth the exact anatomical limits and locality 
within which these morbid processes begin and go on. It 
has been the custom, since, indeed, the days of Plenck and 
Willan, to divide diseases of the skin according to their 
general aspects or naked-eye features, such as lumpiness, and 
redness, or pimples, vesicles, etc, and it has hitherto been 
found convenient to make certain groups according to these 
various types of -aspect, or " elementary lesions" as they are 
called. But some better method will assuredly be devised 
before very long, and probably it will have a pathological 
basis ; for the old Willanian system, however useful, cannot 
be regarded — taking account, as it does, only of the mere 
outward aspect or appearance of eruptions — as anything but 
a tentative arrangement, roughly outlining the physical 
characters of cutaneous disorders. An accurate knowledge 
of elementary lesions, however, is still needed by all stu- 
dents of dermatology preliminary to the fuller study of the 
subject. We shall, therefore, first describe these primary 
lesions, and then proceed to make a few general remarks 
upon the nature of the changes that individually occur in the 
different component textures of the skin. 



THE PATHOLOGY OF THE SKIN. 21 

ELEMENTARY LESIONS. 

These elementary lesions, as before indicated, are the 
types of external form and aspect presented by eruptions of 
the skin. These are nine in number, bearing the designa- 
tions respectively of macules, or stains ; hyperemia, or red- 
ness ; pomphi, or wheals ; papules, or pimples ; vesicules, 
or little bladders ; bullce, or blebs (*". e., bladders larger than 
vesicles) ; pustules, or pustules , squamce, or scales ; and tu- 
bercula, or tubercles (little solid lumps). These several le- 
sions we shall now briefly describe in detail. 

Maculae or Stains For all practical purposes these 

may be said to be of four kinds, viz., pigmentary, chemical, 
parasitic, and hemorrhagic. 

I. Pigmentary stains are usually due to the presence 
in the rete mucosum, and more particularly in the lower 
strata of its cells, of altered coloring matter of the blood in 
the form of pigment granules, or minute dark particles. 
They may be divided into two groups, viz., primary and 
secondary maculae. The primary or idiopathic pigmentary 
stains are few, and consist chiefly of such things as freckles 
and the discolorations left after hyperemia induced by local 
irritants of various kinds. The majority of pigmentary 
maculae belong to the group of secondary stainings, that is 
to say, they do not constitute the sole, or primary, or main 
condition present, but follow in the course of other morbid 
states of importance. They, for instance, occur in and are 
secondary to syphilitic eruption, and in association, in like 
manner, with certain cachexia, such as Addison's disease and 
leprosy. They are left behind by such eruptions as lichen pla- 
nus, and the vitiligo of Willan (xanthelasmoidea of ourselves). 
They are sometimes strictly physiological in character, as 
seen in the bronzing of the forehead, and other parts of the 
surface, in connection with pregnancy and uterine activity of 



22 THE PATHOLOGY OF THE SKIN. 

other forms. Maculae of this kind are not raised, they are 
unaffected by pressure, and are not the seat of any morbid 
sensation. There may be an entire absence of pigment, 
when the skin, of course, looks white. 

II. Chemical stains are seen in the instances of dis- 
colorations from iodine, silver compounds, bile products, and 
the like. 

III. Parasitic maculae are usually of a fawn color, 
and are caused by the presence of fungous elements growing 
between the cuticular cells, as seen in tinea versicolor. 

IV. Hemorrhagic stains are due to the actual extrava- 
sation of blood, or the escape of its coloring matter alone, 
into the skin textures, and the varying hue is accounted for 
by the changes which have taken place in the transuded 
material, as typically portrayed in an ordinary bruise. Pur- 
pura is the chief disease in which extravasation of blood 
into the skin occurs, but an hemorrhagic aspect is assumed 
by variola, by herpes, by lichen planus, the bites of insects, 
and the petechice of febrile states. 

Hyperaemia or Redness may be active (arterial) or 
passive (venous). Active hyperemia consists of redness 
removable by pressure. It may be punctiform, patchy, or 
consist of circles. It mostly is accompanied by swelling 
from effusion of serosity, and the escape of leucocytes ; by 
disordered sensation (pruritus and burning); by a slight rise 
in temperature ; and it is followed by desquamation. It is 
caused by local irritants, by changes in the blood, and by 
excitation of the nerves. It may occasionally exist alone as 
the sole disease, as in the erythemas ; or, as is usually the 
case, it may be a stage or part in the development of more 
complicated changes, as in the inflammatory disorders of the 
skin. All active morbid alteration in the skin is attended 
by hyperemia, more or less pronounced. Passive conges- 
tion of the skin may be said to be the result of some cause 



THE PATHOLOGY OF THE SKIN. 23 

retarding the flow of the blood through the veins towards 
the heart, or, in fact, to be of mechanical origin. 

Pomphi, or Wheals, are raised hyperasmic swellings, 
which vary much in size and shape. They have a palish 
centre, and a red areola in varying proportions. They very 
rapidly form, to as rapidly disappear. Attended by a 
certain feeling of heat in the part together with tingling or 
itching, they are typically portrayed in the sting of the com- 
mon nettle, with which every one is familar. The fugitive 
and capricious character of the wheal is the most charac- 
teristic feature in its behavior. The wheal is significant of 
urticaria. The wheal may be oval, or round, or linear, or 
band-like in form ; the latter generally are the result of 
scratching in a particular direction, and when so produced 
are said to be factitious. In children they are often quite 
small, resembling bug-bites, and are followed by the de- 
posit of lymph in the form of minute, solid, pale papules, 
which may run on into slight vesicles, as the "lichen urti- 
catus" of children, which is a phase of urticaria. Wheals 
are caused by sudden irritation with immediate contraction 
of the capillaries, but this contraction is speedily followed 
by free dilatation and escape of serosity into the tissues, which 
accounts for the redness and the swelling; but the vessels 
beyond the area of dilatation, that is, away from the imme- 
diate seat of the irritation inducing the wheal, are probably 
in a state of spasm ; as soon as this gives way the wheal 
begins to disappear, and as this happens speedily, the wheal 
is essentially fugitive. During the formation of the wheal 
the serosity finds its way to the rete cells, and more particu- 
larly the lax tissue of the papules outside the vessels. It 
exerts, as it augments in amount, some pressure by its dis- 
tending influence, and as the greatest effect is felt about 
the centre or apex of the wheal, the paleness at the corre- 
sponding point on its surface, which is in strong contrast 



24 THE PATHOLOGY OF THE SKIN. 

with that of the bulk of the wheal, is most likely due to the 
emptying of the capillaries at this point by this pressure, and 
the masking of them by this fluid. This is proved by the 
gradual reappearance of the pink blush over the centre of 
the wheal as the effusion and swelling lessen, the white as- 
pect going and the red reappearing pari passu with the 
absorption of the fluid and the diminution in the tension 
of the tissues. Some think that the pale centre is due to 
spasm of the vessels, but facts are clearly against this view. 
In exceptional cases the effusion is so decided and rapid that 
the serosity uplifts the cuticle, and produces a vesicle or 
bulla ; but this is not a common occurrence. In other rare 
instances the effusion of serosity is very great and deep, so 
that large tuberose swellings are induced. These are more 
or less fugitive in character, and are attended by heat and 
itching, but naturally where much fluid is transuded, it takes 
longer to become absorbed. 

Wheals cannot be said to be inflammatory in character, 
because no new products are produced in connection with 
their formation. They are rather developed as a conse- 
quence of an alteration of the calibre of the vessels, induced 
by disordered nervous influence. It is a vaso-motor, and 
not a local, tissue disorder. 

Papulae or Pimples These are small, circumscribed, 

more or less firm elevatious of the surface. The word pimple 
sufficiently expresses their general character. Papules are of 
several kinds, however, and are produced by a variety of 
causes ; for instance, they may result from the presence 
of effused serosity in small amount, or lymph, or a new 
growth in the derma itself; or by swelling, thickening, or 
plugging the follicles. They vary in size somewhat, and in 
color, according to the amount of congestion by which they 
are attended. If very vascular they are small, red, and 
soft ; if due to the presence of solid material in the textures, 



THE PATHOLOGY OF THE SKIN. 25 

they are paler, and, of course, firmer. It is important to 
distinguish true from what may be termed false papules. 
True papules are such as assume and retain the aspect of 
papules from the beginning to the end of their career. In 
other cases what seems to be a papule — but which is false, as 
it were, to its character at the time of observation — may be in 
reality an early stage in the formation of a vesicle or pustule. 
That is to say, when in the development of a vesicle there 
is but slight effusion, the dermic structures are raised into 
papules ; but this is succeeded, as the fluid increases in 
amount and the inflammation progresses, by uplifting of the 
cuticle, the formation of pus, and other changes. It is 
manifestly wrong to designate the papular stage of a vesicle 
as a true papule. It is a potential vesicle, as seen in eczema, 
hydroa, etc. It is of no little moment to remark the dis- 
tinction here pointed out in diagnosing cutaneous eruptions. 
Patches may be and often are formed by the aggregation of 
pimples. Papules are often attended by itching. 

True papules may, clinically, be conveniently regarded as 
of six chief kinds : — 

a. They may be due to hyperemia of the papillae, form- 
ing bright red points, as in strophulus, or the papules 
of certain of the acute specific diseases. 

b. They may consist of turgescent and erected follicles, 
the hair, the sweat, or the sebaceous, as in cases of 
follicular hyperemia, induced by scratching, and in 
slight acne and the early stage of miliaria respec- 
tively. 

c. They may be caused by the deposit of lymph, or by 
cell infiltration about the walls of the follicles, as in 
lichen planus. 

d. They may be actual lymph formations, or cell growths 
in the derma proper, as in lichen, prurigo, and 
syphilis. 

3 



26 THE PATHOLOGY OF THE SKIN. 

e. They are caused by collections of sebum or epithelium, 
or both, in the follicular orifices, as in pityriasis 
pilaris, in which the hair follicles are plugged by 
epithelial exuviae, or in the acne sebacee cornee, in 
which the sebaceous glands are plugged, rasplike, by 
sebum. 

f. Papules are sometimes the result of mere hypertrophy 
of normal tissue, as in papillary warts. 

It will be noted that papules may be situated on three 
chief sites, viz. : the corium, the hair follicles, or at the 
sweat ducts, as in miliaria. 

Vesicles These have hitherto been described as little 

bladders, varying in size from a pin-head to small split peas, 
and caused by uplifting of the cuticle by serous fluid poured 
out by the vessels of the papilla? ; and, further, as either 
single or loculated in structure. But this definition, and 
especially the former portion, must now be regarded as 
affording "an altogether too limited representation of patho- 
logical facts. 

The part of the skin tissue distended into vesicles, and 
the nature of the fluid which causes the distension, vary 
essentially in different cases, but it may be stated that there 
are three principal kinds of vesicles : — 

a. Serous or inflammatory vesicles. 

b. Sweat vesicles, or vesicles formed in connection with 
the sweat ducts ; and — 

c. Lymphatic vesicles. 

a. Serous or inflammatory vesicles are the commonest, by 
far. They rise above the level of the surrounding skin, and 
tend to burst and discharge their contents and dry away. 
Some vesicles burst with difficulty, as in herpes, in fact, these 
often never rupture. Sometimes their contents become 
opalescent or opaque, which is due to the admixture of pus 
with the serosity, thus giving rise to vesico-pustules, which 



THE PATHOLOGY OF THE SKIN. 27 

form yellowish crusts, when their contents dry up. These 
vesicles may be acuminated as in scabies, but usually they 
are more or less globular, as in eczema, or hydroa. They 
may be oval, and perhaps at one period of their course um- 
bilicated, as in varicella. Sometimes they are isolated, as in 
scabies and hydroa; at other times aggregated together into 
patches, as in eczema, or grouped in circular form as in 
herpes. They are usually attended by burning or itching. 
Such are their gross characters. In regard to their mode of 
formation and anatomical structure, it may be said that 
inflammatory vesicles answer to the ordinary ^description 
of vesicles, that is to say, they are due to the escape of 
serosity from the papillary and subpapillary vessels, which 
finds its way to the surface and uplifts the tissue which bars 
its exit. This may in its escape not disturb the rete tissue 
much, but find its way chiefly between the horny and mucous 
layers, raising the former up into vesiculation, as in pem- 
phigus, and mild cases of eczema, probably, in which this 
condition is associated with oedema and cell infiltration of 
the derma ; or in its passage through the rete the fluid may 
cause more or less stretching of these cells into fibres, which 
then form the walls of little loculi in which the fluid is con- 
tained, and in which, when the disease is inflammatory, cell- 
products make their appearance by migration from the 
corium vessels, as is the case in variola, herpes, pustular 
eczema, etc. The inflammatory vesicle, therefore, may be 
single, as in pemphigus, or, as in most of the cases, com- 
pound, as in the common vesicular affections. 

b. Siveat vesicles. In these the vesicles may be elevated 
and globular, as in sudamina, or imbedded in and below the 
level of the skin, as in the earlier stages of dysidrosis. The 
fluid present may be normal sweat, and collected between the 
layers of the epidermis, as in sudamina ; or the fluid may be 
sweat mixed with serosity poured out from the vessels of the 
sweat tubes; in this case the fluid first distends the portion 



28 THE PATHOLOGY OF THE SKIN. 

of the sweat duct in the rete, which is the commence- 
ment of a globular dilatation that by its increase projects 
upon the surface, and may by continued development, col- 
lection of fluid, and junction with other cysts, produce bullce. 
Usually the duct bursts, and the walls of the large vesicle 
are formed in part by the stretched rete tissue, as in dysi- 
drosis. 

c. Lymphatic vesicles, that is to say, vesicles having the 
aspect of clean, transparent, little bladders, and not merely 
minute, soft, little reducible swellings, are observed in lym- 
phaugiomata and elephantoid diseases, and are distensions 
of the lymphatic spaces of the papillas and base of the papilhe. 
They are usually attended with hypertrophy of the fibro- 
cellular texture of the skin, and in fact may form part of and 
stud over a hypertrophic mass. The walls of these vesicles 
are formed not by the rete, not immediately at any rate, but 
by a layer of the tissue of the papillae, though the rete is just 
outside it, and is often thinned by pressure. The lymph vesi- 
cles are lined by endothelium. 

There is another aspect in which the features of vesicles 
may be summarized, and that is from the points of view of 
their single or compound nature. This arrangement affords 
a good general indication of the characters of different vesi- 
cles, and is as follows : — 

A. Single-chambered Vesicles are produced by — 
a. Sweat between the horny layers of the epidermis, as 

in sudamina ; 
h. By serum between the horny and mucous layers, as 

in pemphigus and mild cases of eczema; 

c. A mixture of sweat and serous fluid in a globe formed 
by distension of the sweat tubes and rete tissue im- 
mediately adjoining, as in dysidrosis ; 

d. By lymph distending the lymphatic tissue and its 
spaces in the papillary and subpapillary regions, as 
in lymphangiomata. 



THE PATHOLOGY OF THE SKIN. 29 

B. Compound or Loculated Vesicles are produced by 
the presence of inflammatory fluid and cells, which uplift the 
cuticle and collect in loculi formed by the stretched out rete 
cells and the distended meshes of perhaps the upper corium 
layers, as in variola, herpes, severe eczema, and hydroa, or 
in a blister. 

Pustules. A typical pustule, as generally understood, 
is a small circumscribed elevation of the skin textures pro- 
duced by the presence of pus ; but there are two other forms, 
which must not be lost sight of, viz. the one produced by 
inflammation of the sebaceous glands, as in acne, and the 
other due to suppuration set up in a papule, as in syphilis. 
The vesicle and the pustule differ in the relative amount of 
leucocytes in each. Ordinary pustules vary in size from that 
of a pin's head to a sixpence or shilling, and their yellow 
color is due to the pus ; if dark, to the presence of blood 
coloring matter or actual blood. They are attended with 
more inflammation than vesicles, and by. a deeper affection 
of the tissues, and therefore have harder bases. They tend 
to dry up rapidly into dirty-looking crusts, and sometimes 
leave scars behind. 

True pustules are formed in the same way as vesicles, and 
the pus is contained in loculi, or meshes of the rete, similar 
in structure to those of compound vesicles already described. 
The vesi co-pustule has already been referred to in speaking 
of vesicles. The term is applied to the condition in which 
the aspect of a vesicle is first assumed, but in which pus is 
subsequently produced in distinct amount, so that the aspect 
of the pustule is more or less closely approached. The pus 
is not so freely nor so promptly produced as in the pustule. 

Bullae are really large vesicles or blisters. They are 
primary and secondary. The primary, or true bullae (be- 
cause essential parts of the disease), occur in pemphigus, 
hydroa, pycemic pemphigus, erysipelas, syphilis, and leprosy ; 

3* 



30 THE PATHOLOGY OF THE SKIN. 

and they are developed by friction in some people. The 
secondary, or accidental bullae, occur in dysidrosis, eczema, 
and urticaria. 

Primary bullae vary in size up to that of a large egg ; and 
bullae of different magnitudes may occur together in the same 
patient. They are seen not only in numbers over the body, 
but occasionally they also develop singly. They vary in hue 
according to their age and contents. At first they are trans- 
lucent, and subsequently become opaque or even hemorrhagic 
in aspect from the admixture of blood or its coloring matter 
with their contents, which generally contain albumen, with 
few corpuscular elements, the reaction being alkaline. Ordi- 
nary bulla? are at first tense, then become flaccid ; the walls, 
however, are firm, and do not readily burst, so that, as the 
rule, bullae gradually shrivel away, leaving a red mark and 
some crusting, except in cases associated with constitutional 
cachexia, when there may be more or less ulceration. From 
first to last bullae do not possess any decided areola ; excep- 
tionally when they crowd together very closely, as in pem- 
phigus foliaceus, the secretion of the bullae and a certain 
amount of discharge from the skin dry together into consi- 
derable crusts or flakes. Mostly they are unattended by any 
decided subjective sensations, but, occasionally, attendant 
burning and smarting, as in pemphigus foliaceus, and intoler- 
able itching, as in pemphigus pruriginosus, are present. 

The secondary bullae of eczema are accounted for by the 
non-rupture of several vesicles which join together. They 
are seen especially about the hands. In urticaria, occasion- 
ally small bullae are observed owing to very free and exces- 
sive outpouring of serosity. In dysidrosis bullae occur ; but 
whereas in other cases they are single chambered, in dysi- 
drosis, in their early stage, they are loculated or rather com- 
pound, being produced by the aggregation of a series of 
distended sweat follicles and adjoining rete tissue, projected 
upward bodily, as it were ; the walls of the separate little 



THE PATHOLOGY OP THE SKIN. 31 

vesiculations forming so many partitions which may give 
way later on by the increasing distension of the parts by 
fluid, whereby the loculated is reduced to a single-chambered 
bulla ; the ruptured partitions, however, remaining more or 
less loose in the cavity. Ordinarily, in other diseases, the 
bullae are formed of a single chamber only, from first to last, 
except, perhaps, in early blister, but in this case the parti- 
tions are soon ruptured. 

Squamae or Scales are formed of dried flakes or thin 
layers of detached epidermic scales. They differ from crusts 
in the fact that they are not formed by the drying up of dis- 
charge. Scaliness occurs as a secondary consequence in all 
inflammatory skin diseases; but squamae also form as an 
essential part of squamous inflammation — e. g., psoriasis, 
and pityriasis rubra ; they occur also in hypertrophic condi- 
tions. They may be thin and fine, as in pityriasis simplex, 
or large and flaky, as in pityriasis rubra, in which disease 
they are often arranged like the tiles of a house, and are 
produced and thrown off in great abundance and rapidity. 
They are thin and greasy in seborrhea, and dark and horny 
in ichthyosis. 

Tubercula or Tubercles A tuber culum is a solid 

fleshy lump in the skin formed by the growth of new tissue. 
It is a term applied to any smallish lump which is not large 
enough to deserve the name " tumor," to which, on the 
other hand, the term papule is not applicable. A tubercle 
is, however, a big papule, and there is no real line of de- 
marcation between the two, for oftentimes a papule grows to 
a tubercle, as is seen in syphilis, or lupus. Tubercles occur 
under two main conditions — where there is a hyperplasic 
growth of connective tissue, as in fibroma and keloid, when 
they are said to be homologous ; or there is a formation of a 
new or foreign kind of tissue, as in cancer, lupus, syphilis, 



32 THE PATHOLOGY OF THE SKIN. 

rodent ulcer, leprosy, frambcesia, etc., when the growth is 
termed heterologous. The tubercles in these diseases are, in 
their early stage, round, firm to the touch, and either possess 
the aspect of normal tissue, as in fibroma* or are reddish and 
more or less vascular, as in the other diseases before men- 
tioned. They undergo a variety of changes, such as en- 
largement, aggregation, absorption, softening, or ulceration ; 
but they may remain unchanged for years. When they 
degenerate they lead, after ulceration, to more or less scar- 
ring. Dr. Duhring makes a separate class of the large and 
more pendulous outgrowths from the skin, and terms it 
" tumores." It comprises " alterations in the sebaceous 
glands ; new formations in the corium, connective tissue, 
bloodvessels, and lymphatics." It is a useful clinical ar- 
rangement. 

SECONDARY CHANGES. 

Crusting This is a common condition. The crusts 

are derived mainly from three sources : — 

a. By the drying up of discharge — seroso-purulent fluid, 
or actual pus or blood. These fluids may be poured 
out free upon the surface from inflamed or ulcerated 
surfaces, as in eczema and syphilis, or derived from 
the contents of bullae, as in rupia. 

b. Crusts may also be formed by dried sebum, as in 
seborrhcea. 

c. From the collection together of the elements of pa- 
rasitic fungi, as mfavus. 

Crusts formed by the escape of serum are thin and light- 
colored, often ill-defined; from pus, thick, yellow and with 
definite borders ; from the drying up of bullae, thin and dark- 
ish ; from the drying of sanious pus from ulcers, thick, 
dark-colored, adherent and heaped up ; from collections of 
dried sebum, flat, easily detached and greasy; and from 
favous elements, sulphur colored, pulverulent and honey- 
combed. 



THE PATHOLOGY OF THE SKIN. 33 

Ulceration. — This, like crusting, may be said to arise 
from three sets of causes : — 

a. The most common kind is the result of cachectic in- 
flammation, such as the strumous and syphilitic ; 

b. It may be due to the presence and softening of new- 
growths which replace and destroy the normal tex- 
tures, and which themselves decay in due course, as 
in lupus and cancer ; or 

c. It may result from the softening and decay of actual 
outgrowths from the skin, as in fibroma and yaws. 

Ulcers vary in size, shape, and depth. Strumous ulcers 
are indolent, unhealthy in aspect, with boggy edges and an 
offensive, dirty discharge, mixed with attempts at crusting. 
Syphilitic ulcers have sharp-cut, serrated, everted, but not 
undermined edges. Cancerous ulcers have everted and un- 
dermined edges. They leave behind decided scars. It 
must not be forgotten that superficial ulceration may follow 
common inflammation in ill-nourished people, especially in 
cedematous, congested, and dependent parts, such as the legs. 

Excoriations. — In these the true skin is more or less 
exposed, but it is not otherwise disturbed, and excoriations 
are due to scratching or rubbing of itching parts by the pa- 
tient, or to maceration of any part by fluid, perhaps its ow r n 
secretion, as in intertrigo. Excoriations are observed in a 
number of cases of disease of the skin which are attended by 
itching, for the relief of which scratching is practised, but 
chiefly in eczema, lichen, prurigo, hydroa, psoriasis, scabies, 
phthiriasis, and in cases also of pruritus of the surface with- 
out eruption. Excoriations, therefore, can be truly the sole 
visible condition present, or it may be a superaddition to 
other eruptions, a difference of some importance ; for if there 
be only the signs of an excoriated skin present, the cause of 
the pruritus must be sought for in some blood state or nerve 
disorder, and not in the skin itself. Excoriations are often 



34 THE PATHOLOGY OF THE SKIN. 

seated around the hair follicles alone ; about an eczematous 
spot ; or in a given patch, as in psoriasis. In scabies they 
are found particularly on the front of the arm, the abdomen, 
and thighs ; in phthiriasis about the neck and shoulders, and 
in the form of linear scratching. 

Fissures are linear cracks which occur in parts that 
are rendered dry, hardened, and brittle by infiltration with 
lymph, or about the hands in eczema and psoriasis. 

Sears are left by traumatic injuries, caustics, and by cer- 
tain diseases which ulcerate, such as variola, furunculus, an- 
thrax, pustula maligna, and strumous and syphilitic disease. 
Scars need scarcely be described as regards their general 
appearance. They signify that the true skin has been re- 
moved or destroyed, and replaced by " cicatricial tissue." 

GENERAL OBSERVATIONS ON THE PATHOLOGY OF THE SKIN. 

In describing the " elementary lesions," the intention was 
to convey information regarding the types of form and the 
external aspects which skin diseases assume ; it may now be 
useful to add some few remarks upon the general nature and 
main anatomical seats of the changes that occur in these 
maladies : — 

The Cuticle. 

A. The horny layer — The changes in this structure may 
be said to be almost invariably secondary to changes in the 
rete and deeper tissues below. There are none of moment 
that are of primary origin if we except the results of trau- 
matic or toxic injuries, undue maceration of fluid, and the 
invasion by fungi. This will appear reasonable enough if 
it be remembered that the cells of the horny layer are merely 
the rete cells pushed upward from below, and which have 
undergone desiccation. 



THE PATHOLOGY OF THE SKIN. 35 

The secondary changes are many and various. The cells 
are increased in amount whenever the rete is in a state of 
excitation from pressure and friction, as in corns, warts, or 
as in congestive conditions, especially in psoriasis, where the 
whole rete is eminently hyperplasic ; also in inflammatory 
diseases, as eczema and pityriasis rubra, where a hyper- 
production of scales marks the latter stages of the disease. 
A like condition may be part of a general hyperplasia of the 
tissues of the skin as a whole as in elephantiasis arabum, 
and is congenitally so in ichthyosis. The cells may be dis- 
posed more or less normally, there being only such an excess 
as to cause roughness, or their normal stratification may be 
altogether destroyed by their rapid production and heaping 
together, as in psoriasis. The horny layer is elevated in con- 
nection with portions of the rete cells by fluid issuing from 
beneath, and in some like fashion in the formation of vesi- 
cles as in eczema, or herpes, or it alone may form the walls of 
vesicles or bullae as in pemphigus, or the cells may be only 
swollen, oedematous, and closely packed together with fluid 
amid them as in oedema. The cells may be collected to- 
gether upon the skin and shed not only now and then en 
masse, as in psoriasis, but they may be also shed, again and 
again, in rapid and successive crops, as in pityriasis. Some- 
times they are shed once and for all, as in erythema. 

The cells of the horny layer again may be diminished in 
absolute amount, as in those cases where the nutrition of the 
rete is interfered with by such influences as pressure from 
below and substitution of the normal textures by new growths, 
as in syphilis and lupus. In these cases the cells are disposed 
in irregular scales upon the surface, the flakes .of which 
are often few and fine, but it is important to add that 
the appearance of scaliness is apt to convey at first sight 
the idea of an excessive formation of cuticle, whereas the 
amount of epidermis is less than normal in its total. The 
condition here is a minus ill-stratified, and not a plus ill-stra 
tified one, as it is in psoriasis. 



36 THE PATHOLOGY OF THE SKIN. 

Again the cells may be altered in character more or less, 
retaining the characters of rete cells, from failure to undergo 
the horny transformations, in which case such failure may be 
due to a too rapid and imperfect formation of cells. 

Lastly, vacuolation may, now and then, go on in the cells 
of the horny layer. 

B. The rete Malpighii The changes which occur in this 

layer are very important ; they are primary and secondary, 
and, as before stated, are associated, in most instances, with 
others in the upper layer of the epidermis. Unquestionably, 
morbid processes originate in the rete, and are primary. The 
simplest instances of such primary alterations are seen in the 
hypertrophy of warts, corns, callosities, and notably, in our 
belief, in psoriasis, in which diseased state the two layers of 
epidermis are concerned. We have long taught, and our con- 
victions on this point are based in part upon careful micro- 
scopical observations, that psoriasis is to be regarded as due 
to an hyper-activity of the rete cells, which increase so freely 
as to be extended down beside the papilla? into the corium 
tissue, and also spread in undue proportion upwards. The 
nuclei of the cells are active, they freely multiply, and 
rapid cell division takes place, vacuolation being marked in 
many cells ; the vessel changes being probably secondary. 
Another instance of the origination of disease in the rete 
occurs, we believe, in epithelioma, large processes of morbid 
rete tissue being projected downwards, portions finding their 
way along the lax connective tissue and following, probably, 
the lymphatic tracts toward the glands, and developing into 
onion-like bodies en route ; the phenomena of congestion 
and inflammation being concurrent. A congenital hyper- 
plasia of the epidermis associated with papillary hypertrophy 
is illustrated by ichthyosis. 

Pigmentary deposit in the lower strata of the rete cells 
may be a primary change, but it is, as the rule, secondary to 



THE PATHOLOGY OF THE SKIN. 37 

other morbid conditions, especially such as are associated 
with cachexia. 

The alterations in the rete tissue which occur in conges- 
tive and inflammatory diseases are very common and distinct, 
but it must be understood that the rete does not actively 
participate in these changes, but rather is altered as a con- 
sequence of the escape of fluid and migration of cells into 
it from the vessels beneath. Therefore the changes are, 
strictly speaking, secondary to the vascular disorder. As a 
consequence of the escape of fluid into the rete tissue, the 
cells swell and become loosened, separated, or put upon the 
stretch, as the fluid increases in amount, and travels to the 
surface. As has been explained in speaking of vesicles, 
loculi are often formed by the separate and stretched out 
rete cells. If these loculi open to the surface, the rete layer 
is more or less exposed, and may continue to give exit to a 
"discharge." The migration of leucocytes from the vessels 
of the papillae and their subsequent change account for the 
presence of pus in the rete meshes. If the inflammation be 
severe and continuous, the nutrition of the rete may be so 
interfered with that it is more or less destroyed. Such 
changes as the above described as are induced by the pre- 
sence of fluid occur in eczema, herpes, hydroa, blister, dysi- 
drosis in part, pemphigus, and such alterations as are de- 
pendent upon the migration of cells into the rete are observed 
in eczema, herpes, impetigo, variola, etc. 

It will be noticed that the primary seat of change is the 
vascular tract below, and that the cell migration and final 
transit may concur, as in eczema, or it may be mainly fluid 
escaping, as in pemphigus, whilst the cell activity is compara- 
tively insignificant or nil. Another principal alteration in 
the rete is the invasion, destruction, or replacement of its 
tissue by new or foreign tissue. In this case the production 
of rete cells is gradually interfered with, and the normal 
tissue becomes atrophied. Such change is seen in syphilis, 
4 



38 THE PATHOLOGY OF THE SKIN. 

lupus, and rodent ulcer. The rete, however, is not alone nor 
primarily affected ; the corium, in its superficial or deep layer, 
being the seat of the mischief in the first instance. The rete 
may be reduced to a thin layer, or be completely gone in 
parts, or small areas may remain isolated as it were by the 
new cell-growth around, the whole being finally replaced by 
cicatricial tissue where ulceration has occurred. 

Somewhat similar results are produced by pressure upon 
the rete below by molluscum tumors, cysts, lymphangiomatous 
vesiculations, which form in the papillary layer, etc. 

Vacuolation of the cells in psoriasis, and some other con- 
ditions, has already been referred to. 

The Corium. — The changes in the fibro-cellular struc- 
ture of the corium are also primary and secondary. The 
primary consist mainly in an increase — a plus state — of the 
connective tissue elements, and, as an independent condition, 
is seen in morphoea, keloid, fibroma. The relative amount 
of cells and fibres varies. In the one case the tissue is lax, 
and contains many cells as in fibroma ; in other instances 
the fibres predominate, forming a dense, tough mass of tissue, 
as in keloid. It is an open question whether the cells of 
certain new growths that invade the corium primarily, such 
as lupus, syphilis, elephantiasis, are derived from the cell- 
elements of the connective tissue of the corium, or from the 
blood-current, but probably the latter. 

In any case " neoplasmata" lead to destruction and 
atrophy of the corium tissue. In xanthoma the connective 
tissue undergoes a fatty change. 

The secondary changes in the corium have reference to 
prior changes in the vessels. The corium tissue is rapidly 
rarefied about the vessels by the escape of fluid from them, 
as in oedema, and this is specially so in the papillary layer. 
It is always more or less hypertrophied, as the result of vas- 
cular excitement of any decided duration. It is infiltrated 



THE PATHOLOGY OF THE SKIN. 39 

with lymph, serosity, or cell-growths, first about and then 
beyond the vessels in inflammatory disease, and may suffer 
more or less injury or atrophy in consequence, especially in 
its papillary layer. The cells which escape from the vessels 
(leucocytes or wandering cells) into the corium are no doubt 
the source of a number of new growths, according to the 
influence exerted upon them by general and local conditions. 
In intense and long-continued inflammatory infiltration, the 
deeper layers are involved, and the occurrence of induration, 
fatty, and atrophic changes — some or all of these are said 
to occur. The effect of neoplasmata in inducing similar 
destructive changes has been already noticed. 

The papillae are enlarged to some extent in pso7*iasis, but, 
as Dr. Robinson points out, such an appearance is often de- 
ceptive, owing to the growth downwards of the interpapillary 
portions of the rete. 

The portion of the connective tissue adjoining the seba- 
ceous glands becomes specially involved in inflammatory 
and other changes in those glands, as in acne or sycosis, and 
especially in strumous subjects. 

The papillae too are enlarged and elongated where the 
lymphatic tissue and spaces augment and increase in size, 
as in elephantiasis arabum, but this is a secondary change, 
perhaps. Where lymphatic or blood cysts form either in 
the papillary or subpapillary localities, the tissue around may 
be pushed aside and thinned by pressure. 

The corium is also the seat of certain animal parasites, 
such as the Guinea worm, or parent filaria, and abscesses 
follow their presence. 

The Vessels The bloodvessels are primarily con- 
cerned and hyperplasic in teleangiomata, or vessel tumors, 
and naevoid growths. Also in most congestive and inflam- 
matory affections, except, of course, where the inflammation 



40 THE PATHOLOGY OP THE SKIN. 

is secondarily induced by the irritation of morbid textural 
alterations. In inflammatory disorders, the vessels are en- 
larged or dilated, and frequently augmented in amount, the 
veins being especially numerous, and the capillaries of the 
papillae particularly prominent and active. The results of 
" vessel activity," viz., effusion into the tissues, and dis- 
turbance by the presence and results of cell infiltration in 
the rete and papillary layers, have been dealt with generally 
in the description of vesicles and pustules. It is necessary 
here to point out that the degree and extent of the arterial 
and venous excitement depend upon the nature of the ex- 
citing cause. It may be very temporary, as in urticaria, 
where there is spasm of the vessels of short duration. It is 
more prolonged, but still comparatively of short duration in 
other erythemata, due to the operation of temporary causes, 
such as chill, or excessive heat, or "rheumatic" disturbance. 
It is prolonged and developed with all its more serious 
consequences, when excited by blood disorders, or chronic 
nervous causes, or diathetic conditions. 

In some cases the vessels of the more superficial strata of 
the corium, and especially the papules, are mainly or solely 
affected, as in psoriasis, lichen, and prurigo ; in others those 
of the longitudinal plexus are chiefly involved, as in pity- 
riasis rubra. In other instances the vessels generally are 
implicated, as in severe eczema. 

It is important to distinguish between vessel excitement 
leading to secondary changes in the textures, as in the inflam- 
mations, and that which occurs as the result of tissue ac- 
tivity itself, as in psoriasis and cancer. 

No doubt the vaso-motor system of nerves plays a great 
part in determining the occurrence of various congestive 
states of the skin, as in lichen rubra and pityriasis rubra, 
but no facts are at present forthcoming to enable the patho- 
logist to offer any satisfactory conclusions upon the subject. 



THE PATHOLOGY OF THE SKIN. 41 

The Lymphatic System plays an important part in 
many skin diseases in our estimation. The lymphatic ves- 
sels may be primarily or secondarily affected. Primarily 
they may be enlarged and increased in number and size, both 
as regards the juice tracts and the actual vessels, where the 
tissues are generally hyperplasic, as in lymphangiomata. 
We have referred to this in speaking of vesicles, but the 
changes are mostly secondary to other conditions. The 
lymphatic tissue seems to be more or less in a state of ac- 
tivity whenever the corium tissue is specially involved in 
disease, according to our own observations, as, for example, 
when the connective tissue is hyperplasic, or involved in 
inflammation, or when it is the seat of new growths. In 
some of these cases the lymphatics are in a condition of ex- 
aggeration, and more or less dilatation in parts. It seems 
that the office of the lymphatics is to regulate the amount 
of nutrient material retained in the connective tissues, and 
where great change is occurring, or the supply of fluid and 
cell from the blood current is excessive, the lymphatics are 
in a very active condition, in order to be able, as it were, 
to successfully remove the overplus. This is observed in 
elephantiasis arabum, lymph scrotum, and other diseases 
where indeed new lymphatics even may form in the enlarged 
papillae. It is probable that it is along the lymphatic juice 
tracts that many diseases spread from the more superficial 
to the deeper parts, as in epithelioma, farcy, erysipelas, etc. 

Nerves Of the organic changes that occur in nerves 

we know far too little. We know that in herpes zoster, lep- 
rosy, syphilis, ncevus, and teleangiectasis, and some other 
diseases, they have been found diseased, but the field of in- 
quiry in this direction remains comparatively unexplored, 
although it is a rich one. 

The Glands. — These are subjected to a variety of 
changes, both primary and secondary. But it is important 

4* 



42 THE PATHOLOGY OF THE SKIN. 

to observe that whilst these organs are disturbed secondarily 
in several general affections of the body, or in common with 
like diseased conditions of the adjoining textures, many of 
the disorders to which they are liable are, on the other hand,- 
not only confined to them, but are of a special and different 
nature from those observed in other parts of the body. This is 
accounted for by the existence of a special structure in these 
glands devoted to the special functions they perform. A 
new set of conditions therefore is observed in glandular 
disorders. So long, of course, as the fibro-cellular texture 
of the walls, or even the epithelial linings of the glands, or 
their periacinous lymphatic tissue and spaces, and their ves- 
sels, are the seat of disease, in connection with or independ- 
ently of the affection of other structures in the skin, as in 
congestion, syphilis, lupus, and cancer, for example, a simi- 
larity in pathological appearances is observed, but when the 
true gland structure or any of its functions is involved this 
ceases. But even if in the former case the histological ap- 
pearances are alike clinically, there are differences observable 
to the naked eye in the case of the sebaceous glands, because 
these glands are mostly irritated by the morbid action about 
them, and pour out an excess of secretion which crusts on 
the surface, and forms like plugs on its extracting duct, the 
special amplification of, or localization of the disease to, the 
sebaceous glands being evidenced by this feature, as in lupus 
erythematodes ; disseminated follicular lupus; syphilitic 
acne. The sweat-glands, being more deeply seated, escape 
more usually. 

Examples of secondary disease are syphilitic and stru- 
mous acne, or cortical sudamina, or miliaria, or atrophy of 
the glands from the pressure of new growths and ulcerations. 
Examples of concurrent disease in the sebaceous glands are 
their enlargement in elephantiasis, and leprosy, and other 
diseases, attended with general textural hypertrophy of the 



THE PATHOLOGY OF THE SKIN. 43 

textures, the infiltration of the gland with lupoid cell-growth, 
or cancer-elements, with a like state in the corium generally. 
The primary diseases are numerous. They have reference 
to augmented, or diminished, or depraved secretion of sebum 
or sweat, as the case may be, by which the skin is rendered 
dryer or moister, or more oily and greasy. The secretion 
may collect in the ducts or in the actual glands, and irritate 
and inflame, inducing acne or dysidrosis, or distend the 
structure into cysts. Congestive and inflammatory disorders 
may arise too from a variety of causes, even the use of particu- 
lar drugs, as in bromide and iodide acne. In undue activity 
of the fatty gland, as in molluscum, vacuolation and cell- 
division are admirably seen. In gland diseases a very inte- 
resting field of inquiry is opened in reference also to the 
congenital defects of gland function, as in ichthyosis ; the 
modification of function by constitutional peculiarities as 
exhibited by the hyperproduction of sebum by strumous 
subjects ; the results of undue stimulation by baths, and by 
medicinal substances used both externally and internally, the 
effects of blood-poisons, and the influence of defective or dis- 
ordered nervous influence. 

The Hair-follicles The contained hairs, the follicles 

themselves, and their linings and walls, are subject to a 
number of important changes, and these are mostly primary. 
The hairs may be hypertrophied, or atrophied, or be textur- 
ally changed, as in fragilitas crinium, or be invaded and ren- 
dered dull, dry, swollen, split up, and brittle by the invasion 
of fungi, etc. The epithelial linings are augmented as to 
their cell-elements in psoriasis, lichen planus, etc., and ro- 
dent ulcer probably takes origin chiefly from the outer root 
sheath of the hairs. The fibro-cellular texture and contained 
vessels of the walls participate in congestive changes, which 
also attack at the same time the non-follicular part of the 
skin, as in the inflammations ; and they are also at times the 



44 CHART OF SKIN DISEASES. 

seat of primary congestive and inflammatory changes pro- 
duced under the influence of irritants of all kinds, such as 
scratching, heat, friction, becoming definitely inflamed in 
sycosis, and under special conditions of weak health. The 
periacinous lymphatic channels and tissue participate in the 
changes in lymphatic diseases generally. 

Such is a brief sketch of the general nature and character 
of the minute changes in the skin and its several textures. 
It is only intended as a sketch to convey to the student a 
general idea of the origin, connection, and sequence of such 
changes. We believe it will be useful to beginners in der- 
matology. But it is important to note, in making use of 
the pathological data of any given disease, that these must 
be estimated in the mass and as a whole, not piecemeal in 
short, and also in connection with clinical facts. There is a 
fashion in vogue of trusting too much to the microscope in 
dermatological research ; signal error is the result. 



SECTION III. 

CLASSIFICATION, OR DIAGNOSTIC CHART OF SKIN 
DISEASES. 

The following list, or semi-chart, conveys a good, general 
idea of the various eruptions met with in the skin, regarded 
from a clinical point of view. The list comprises : — 

1. Eruptions occurring in connection with 
the acute specific or zymotic diseases, including 
the variolous rash, roseola variolosa, vaccinia and roseola 
vaccinia, the rashes of typhus, typhoid, rubeola, rubeola 
notha, scarlatina, glanders and farcy, and dengue. These 
are important in reference to the differential diagnosis of 
skin diseases. 



CHART OF SKIN DISEASES. 45 

2. Eruptions, the local manifestations of dia- 
thetic states, comprise scrofuloderma, or scrofulous in- 
flammation; syphilodermata, or syphilitic eruptions; leprous 
eruptions; frambcesia or yaws; eruptions occurring in con- 
nection with endemic cachexice, such as Oriental Sore, the 
Paranghi disease of Ceylon, etc. 

3. Local inflammations, comprising : — . 
Erythematous inflammation ; the chief feature consisting 

in the presence of hypersemia, mainly affecting the papillary 
layer, with or without some slight consequent effusion of 
serosity, swelling of the rete cells, rarely vesiculation, but 
subsequent desquamation. The chief erythematous diseases 
are : — 

Erythema, intertrigo, roseola, and urticaria. 
Catarrhal inflammation, characterized by vascular excite- 
ment, with serous effusion into the corium, together with 
the escape of leucocytes into the same tissue from which pus 
is subsequently produced, giving rise to sero-purulent dis- 
charge and crusting. Under this head rank : — 

Eczem,a and impetigo. 
Plastic inflammation, essentially papular, due to effusion 
of plastic lymph into the papillary layer, and sometimes the 
deeper dermic layer ; including — 

Lichen and prurigo. 
Bullous inflammation, the chief feature being the develop- 
ment of bullae as an essential phenomenon. It includes 

Herpes, pemphigus, and hydroa. 
Suppurative inflammation, characterized by the develop- 
ment of pustules, superficial and painless, or deeply seated 
and painful. It comprises — 

Impetigo contagiosa, ecthyma, and fur unculus. 
Squamous inflammation, characterized by hypersemia of 
the derma, and hyperplastic growth of cuticle, with a vary- 
ing amount of secondary thickening. This group includes — 

Pityriasis rubra and psoiHasis. 



46 CHART OF SKIN DISEASES. 

4. Hypertrophic and atrophic diseases : — 

A. Hypertrophic. 

I. In which the epithelial layers are mainly affected. 
Pityriasis, xeroderma, ichthyosis, warts and corns. 

II. When the connective tissues of the skin are spe- 

cially involved — 
Keloid, fibroma, morphcea, and scleroderma. 

III. Vessels of the skin affected primarily : — 

1. The arteries and veins — teleangiomata. 

2. The lymphatic vessels — lymphangiomata. 

B. Atrophic. 

Senile atrophy, linear atrophy, general marasmus. 

5. New formations, the characteristic being the 
growth of new tissue made up of granulation cells, or altered 
and proliferating connective tissue of epithelial cells, cells 
which invade, destroy, and finally replace the healthy struc- 
tures, the new growth itself undergoing degenerate changes 
in due course. 

Lupus, cancer, rodent ulcer, and xanthoma (?) 

6. Hemorrhagic disorders (cutaneous), consisting of 
effusion of blood, in points or patches, uninfluenced by pres- 
sure. 

Purpura. 

7. Neuroses, in which the nerves are primarily dis- 
ordered, with or without organic changes at the outset. 

A. Functional. — Hyperesthesia, ancesthesia, and pru- 
ritus. 

B. Organic Neuromata, nerve ncevus, and secondary 

changes in other disorders. 

8. Pigmentary alterations. There are two groups : 
(1) those consisting primarily of deposit or alteration of pig- 
ment in the rete, as in Melasma, leucopathia, etc. ; and (2) 
cases of pigmentation, secondary to other diseases, as in 
Addison's disease, and the like. 



CHART OF SKIN DISEASES. 47 

9. Parasitic diseases, which comprise : — 

A. Animal, illustrated by scabies, phthiriasis, erup- 
tions due to gnat -bites, fleas, etc. ; abscess due to fila- 
ria, etc. 

B. Vegetable, including tinea favosa, tinea tonsurans, 
tinea circinata, tinea Icerion, tinea versicolor, tinea 
sycosis, tinea decalvans, and onychomycosis. 

10. Diseases of the glands and appendages are 
divisible into : — 

A. Diseases of the sweat glands and follicles, as exces- 
sive secretion (hyperidrosis) ; diminished secretion 
panidrosis') ; altered secretion (such as chromidrosis, 
colored sweating, and osmidrosis, offensive sweating) ; 
and those which may be termed congestive and in- 
flammatory, as miliaria, sudamina, lichen tropicus, 
strophulus, dysidrosis, hydro adenitis, and sweat cysts. 

B. Diseases of the sebaceous glands, as excessive secre- 
tion (seborrhosa) ; diminished secretion (asteatodes) ; 
altered secretion, with or without retention (allostea- 
todes, exanthelasma) ; retention of secretion without 
inflammation (mollascum, horns) ; slight retention 
with inflammation (acne). 

C. Diseases of the hair and hair follicles, as excessive 
growth (hairy ncevi, moles, hirsuties) ; diminished 
growth, constituting partial or absolute baldness (alo- 
pecia) ; textural alteration (fragilitas) ; inflammation 
of the follicles (sycosis). 

D. Diseases of the nails, including changes occurring in 
syphilis, lichen ruber, general eczema, psoriasis, 
pityriasis rubra, and struma; inflammation of the 
matrix, as in onychia; or in the parasitic disease 
termed onychomycosis, caused by the favus parasite 
(the trichophyton) ; also hypertrophy, atrophy, and 
corn of the nail. 



48 CHART OF SKIN DISEASES. 

There are, then, ten groups of skin disease, viz. : the 
Eruptions of the Acute Specific Diseases ; Local Inflamma- 
tions ; Diathetic Diseases ; Hyper- and A-trophic Diseases ; 
New Formations ; Hemorrhagic, Neurotic, and Pigmentary 
Diseases ; Disorders of the Hair and Glands and their Ap- 
pendages. Such is the clinical classification that may be 
given at an examination. Every skin disease must fall into 
one of these groups, and it soon becomes an easy matter to 
refer any disease before the observer to its proper class. 

[Peculiarities of Skin Diseases in the United 

States. 

It is a well-known fact that a malady often undergoes 
definite modifications under changed external conditions, 
such as altered climatic and hygienic surroundings. Indeed, 
the subject of the geographical distribution of disease has 
ever afforded an attractive field for the medical philosopher ; 
furnishing, as it does, data which, if thoroughly appreciated, 
may prove to be valuable evidence both as to the etiology 
and the claims for specific character of certain disorders. 
The medical profession in the United States have no reason 
to be ashamed of the labors and results of those of their 
number who have especially cultivated the subject of skin 
diseases ; for their recorded observations and careful investi- 
gations have contributed materially to the progress of modern 
dermatology and its establishment upon sound scientific 
principles. From their experience we learn that there are 
not only some generally recognized variations in type of 
certain skin affections, but also that there are others, which, 
though quite frequent in their occurrence in Europe, are 
rarely met with in America, and vice versa. 

A general agreement among dermatologists upon the sub- 
jects of pathology and nomenclature of skin diseases would 
alone enable such a rigid contrast to be made as would com- 
pletely satisfy the demands of science. Such an exact com- 



CHART OF SKIN DISEASES. 49 

parison is not practicable at present, although a rapidly 
increasing consensus of opinion among systematic writers 
upon these subjects, more particularly observed in the last 
quarter of a century, warrants the hope that this may be 
accomplished in the near future. 

In the mean time we may, in a general way, formulate 
the prominent characteristics of skin disorders as they occur 
in this country. Prof. James C. White, 1 of Harvard, from 
a careful study of American statistics and extended personal 
observation, has arrived at the following conclusions : — 

I. Certain obscure affections the etiology of which is little 
if at all understood, even in those parts of Europe to which 
they are mostly confined* may be regarded as practically 
non-existent among us. Such are prurigo, pellagra, and 
lichen exudativus ruber. 

II. Certain diseases, directly connected with and depen- 
dent upon poverty and habits of personal uncleanliness, are 
less prevalent in the United States than in those parts of 
Europe of which we have sufficient statistical information 
for a comparison. Examples of this class are the animal 
parasitic affections especially. 

III. Some cutaneous affections of grave character, which 
are dependent upon or form a part of serious constitutional 
disorders, are of less frequent occurrence amongst us than 
in Europe in general, or those parts of it where they are 
endemic. Lupus, the syphilodermata (?), and leprosy are 
the most marked instances of this class. 

IV. Certain disorders of the skin, especially those of its 
glandular systems and those connected more immediately 
with its nervous system, are apparently more prevalent with 
us than in Europe. The most notable examples of the for- 
mer are seborrhcea, acne, and possibly the heat-rashes ; of 
the latter, herpes, urticaria, and pruritis. 

1 Trans. Int. Med. Congress, 1876, Phila., 1877, p. 681. 
5 



50 CHART OF SKIN DISEASES. 

In addition to these valuable observations, it may not be 
amiss to call the reader's attention to the limitation of 
leprosy (elephantiasis graecorum) within particular districts. 
Existing in India, China, Egypt, certain parts of Norway 
and Sweden and the Sandwich Islands, true leprosy is only 
very rarely encountered in the United States, and almost 
never in the person of a native. It may be found among 
immigrants in the Norwegian settlements in the Northwest ; 
also among the Asiatics in California. It is also seen in 
Central America and Mexico, but is probably never endemic 
in this country. 

Syphilitic skin diseases are common in America as in 
Europe, and when neglected are doubtless equally severe in 
their manifestations ; but in this country they are less fre- 
quently accompanied by such profound degradation of the 
system under the influence of accompanying filth, poverty, 
and insanitary surroundings, than they are in foreign 
countries. Lupus vulgaris, according to Dr. Duhring, is 
much milder here than in Europe; and cases of lupus erythe- 
matosis are relatively much more common in America. 

At the last meeting of the American Dermatological 
Association 1 the following Classification and Nomen- 
clature was adopted : — 

CLASSIFICATION AND NOMENCLATURE OF DISEASES OF 

THE SKIN. 

ADOPTED BY THE AMERICAN DERMATOLOGICAL ASSOCIATION. 

Class I. — Disorders of the Glands. 

1. Of the Sweat Glands. 

Hyperidrosis. Bromidrosis. 

Miliaria crystallina. Chromidrosis. 

Anidrosis. 

1 Held at Saratoga, August, 1878. 



CHART OF SKIN DISEASES. 



51 



2. Of the Sebaceous Glands. 

Seborrhoea. Cysts. 

(a) oleosa. (a) milium. 

(b) sicca. (6) wen. 
Comedo. Molluscnm sebaceum. 

Diminished secretion. 

Class II Inflammations. 



Exanthemata. 
Erythema simplex. 
Erythema multiforme. 

(a) papulatum. 

(b) bullosum. 

(c) nodosum. 
Urticaria. 
Furuncle. 
Anthrax. 

Phlegmona diffusa. 
Pustula maligna. 
Herpes. 

(a) facialis. 

(b) progenitalis. 
Herpes zoster. 
Psoriasis. 
Dermatitis. x 

(«) traumatica. 
(6) venenata. 

(c) calorica. 



Pityriasis rubra. 
Lichen. 

(a) planus. 

(6) ruber. 
Eczema. 

(a) erythematosum. 

(b) papillosum. 

(c) vesiculosum. 

(d) madidans. 

(e) pustulosum. 

(f) rubrum. 
iff) squamosum. 

Prurigo. 

Acne. 

Impetigo. 

Impetigo contagiosa. 

Impetigo herpetiformis. 

Erysipelas. 

Ecthyma. 

Pemphigus. 



Class III Hemorrhages. 

Purpura. 

(a) simplex. (b) hemorrhagica. 



1 These indicating affections not properly included under other 
titles of this class. 



52 



CHART OP SKIN DISEASES. 



Class IV Hypertrophies. 

1. Of Pigment. 
Lentigo. Chloasma. 

(a) locale. 
(h) universale. 

2. Of Epidermal and Papillary Layers. 



Keratosis. 

(a) pilaris. 

(b) senilis. 
Callositas. 
Verruca. 
Clavus. 



Cornu cutaneum. 
Verruca necrogenica. 
Xerosis. 
Ichthyosis. 
Ichthyosis of nail. 
Hirsuties. 



3. Of Connective Tissue. 

Scleroderma. Rosacea. 

Sclerema neonatorum. (a) erythematosa. 

Morphoea. (£>) hypertrophica. 

Elephantiasis Arabum. Framboesia. 



Leucoderma. 
Albinismus. 



Alopecia. 
Alopecia areata. 



Atrophia senilis. 



Class V Atrophies. 

1. Of Pigment. 

Vitiligo. 
Canities. 

2. Of Hair. 

Alopecia furfuracea. 
Atrophia pilorum propria. 

3. Of Nail. 

4. Of Cutis. 

Atrophia maculosa et striata. 



CHART OF SKIN DISEASES. 



53 



Keloid. 

Cicatrix. 

Fibroma. 



Class VI New Growths. 

1. Of Connective Tissue. 

Neuroma. 
Xanthoma. 



Angioma. 



2. Of Vessels. 

Angioma cavernosnm. 
Angioma pigmentosum et Lymphangioma, 
atrophicum. 

3. Of Granulation Tissue. 



Rhino-scleroma. 
Lupus erythematosus. 
Lupus vulgaris. 
Lepra. 

(a) tuberosa. 

(b) maculosa. 

(c) ansesthetica. 
Scrofuloderma. 



Syphiloderma. 

(«) erythematosum. 

(b) papulosum. 

(c) pustulosum. 

(d) tuberculosum. 

(e) gummatosum. 
Carcinoma. 



Class VII Ulcers. 

Class VIII Neuroses. 



Hyperesthesia. 

(a) pruritus. 

(b) dermatalgia. 



Anaesthesia. 



Class IX Parasitic Affections. 

1. Vegetable. 

Tinea favosa. (5) tonsurans. 

Tinea tricophytina. (c) sycosis. 

(«) circinata. 



Tinea versicolor. 



Scabies. 
Pediculosis capitis. 



2. Animal. 

Pediculosis corporis. 
Pediculosis pubis. — Ed.] 
5* 



54 THE CAUSES OF SKIN DISEASES. 



SECTION IV. 

THE CAUSES OF SKIN DISEASES. 

In the previous section a general summary was presented 
of the different varieties of skin diseases in the form of a 
tabular classification. In this section a sketch of the causes 
of these diseases will be given ; they may be conveniently 
ranged under two heads : — 

1. Those which act from within the system, or internal 
causes. 

2. Those which act from without, or external causes. 
There are some who think that the latter are much more 

frequent in their operation and much more potent than the 
former, but it is very doubtful if such is really the case. 

It must be remembered that a combination of these may 
constitute the real cause of a skin disease. But it will be 
useful to consider the two classes separately for the moment. 

A. Internal Causes Amongst these the most impor- 
tant are : — 

a. Hereditary tendency to a given disease, such as in the 
case of ichthyosis or psoriasis. It may give rise to a purely 
local affection, or to a more or less general disease — i. e., one 
involving the skin locally and the general health as well. 

b. Blood poisoning, by certain animal or vegetable 
poisons, inducing specific eruptions, as in the acute specific 
diseases, syphilis, or disorders derived from eating shell-fish 
and some other articles of food. It often results from defi- 
cient excretion, or the undue retention of biliary, renal, or 
intestinal excreta, giving to the blood an acrid character. 
It may be also brought on by long-continued dyspepsia, 
either from dietetic errors or otherwise ; by the presence of 



THE CAUSES OF SKIN DISEASES. 55 

medicinal substances in the blood (e. g., potassium bromide, 
belladonna, or copaiba) ; by the accumulation of lactic or 
uric acids, as in rheumatism and gout, which often excite 
eruptions or impart an inflammatory character to them ; by 
poverty, which depraves the blood and leads to cachexia ; by 
the imperfect fulfilment by certain organs of their natural 
functions, as menstruation, perspiration, and the hepatic or 
renal excretion. 

c. Nerve disturbance, which acts in one of four ways. 
Firstly, by inducing changes in the calibre of the vessels by 
which the blood supply and fluid transudation are affected, 
as in the erythemata. Secondly, by directly encouraging 
tissue change, as in herpes, hydroa, pemphigus, and prurigo. 
Thirdly, by the loss of control over the skin nutrition, which 
follows from nervous debility, allowing morbid action of all 
kinds in the skin to take place more readily. Fourthly, by 
the transmission of irritation through reflex action, by which 
eruptions may be excited or aggravated. 

d. An acquired, innate, or rather an actual, disposition 
in the shin tissues themselves to take on a diseased condition. 
This is a point on which special stress is laid. It is pretty 
certain that many diseases of the skin must originate in a 
disordered behavior of the tissues themselves, and do not 
necessarily depend for their cause upon any general defect of 
nutrition. For instance, cancer is a case in point; and so 
with warty growths of all kinds, such as fibroma, keloid, and 
perhaps lupus. In some cases there is simply an excess of 
growth, a plus state of the nutrition of the tissue and nothing 
more ; or it may be a minus condition. In other instances 
it is a perverted nutrition, a deviation in the type of the 
tissue, as in cutaneous cancer. In fact, Group 4, and many 
of the diseases in Group 10 of the classification given in the 
preceding section illustrate this point. 

It is asserted by most writers that hypertrophy and 
atrophy, the simpler and homologous changes, are, in reality, 



56 THE CAUSES OF SKIN DISEASES. 

merely the consequence of the presence in the blood of a 
greater or less amount of the pabulum of the particular tissue 
affected. But if these pabula be in excess, which has not 
been satisfactorily proved, the hypertrophy would not occur 
unless the tissues were thus disposed to appropriate and 
use them more freely than usual ; and if such a disposition 
existed in a degree less than that in healthy nutrition, atro- 
phy would result. So that, after all, the formative capacity, 
or the assimilative activity, of the tissues themselves is an 
important element in these plus and minus states of growth. 
The explanation given above — viz., that the tissues them- 
selves are hyperactive in the diseases in question — may, 
therefore, be true, and certainly if the tissues themselves ex- 
hibit a tendency to hyperplasia, nature will answer the 
demand for an increased supply of pabulum. 

In the case of perverted nutrition or heterologous forma- 
tions, the changes it seems to us are as readily explained by 
a primary modification of the same "formative capacity" as 
by the supposition of an altered character of growth, the 
immediate consequence of the supply of a special kind of 
pabulum. 

e. Climacteric or endemic injluences induce skin disorder 
by depraving the nutrition of the body in particular ways, as 
in elephantiasis arabum, J'rambaesia, or by affording oppor- 
tunity for the operation of special endemic causes, such as 
special parasites, ex., the filariae, etc. 

B. External Causes Some of these influence the 

general health for evil, and so disorder the skin indirectly ; 
others act directly upon the skin. 

1. Among the external causes acting directly upon the 
skin, the most important are : Scratching, which may excite 
and always aggravates disease, especially if it happen to be 
of an inflammatory nature ; and which may, in contagious 
cases, spread it from place to place, as in scabies and im- 



THE CAUSES OF SKIN DISEASES. 57 

petigo contagiosa. Local irritants of all kinds — ex., cold, 
heat, friction, flannel worn next to the skin, irritants, plas- 
ters, fluids, and applications of all kinds ; irritating sub- 
stances, such as lime, sugar, flour, washing soda producing 
bricklayers', bakers', grocers', and washerwomen's itch ; un- 
wholesome handicrafts ; dyes, contusions, animal and vege- 
table parasites of all kinds ; medicinal applications and want 
of care of the skin in the dirty and ill-fed, are fruitful sources 
of disease. 

2. Amongst the external causes that act indirectly upon 
the skin, through their influence upon the general health, 
may be mentioned : Neglect of cleanliness, defective clothing, 
unsanitary surroundings, climatic influences, and the like ; 
also animal poisons inoculated into the bodily surface, etc. 

Clinically, as before hinted, it is of the highest moment to 
be acquainted with the fact that, as a rule, these several 
causes not only vary in character, but do not operate in a 
solitary or individual way. To put it in another shape ; (1) 
these influences or agencies are, in reality, divisible into^re- 
disposing, exciting, producing, and intensifying causes ; and 
further (2) the true cause of the state of any given disease is 
made up of a number of phenomena or agencies in combined 
operation. These are points of great practical importance 
in reference to the treatment of skin diseases. 

In reference to the first, it may be said that many so-called 
local causes usually only predispose to, although they are 
thought to excite, eruption. For instance, debilitating occu- 
pations render a man much more liable to be affected by the 
handling of irritants ; in a bad climate, the system generally 
is disordered in addition to the skin, and the latter is so ren- 
dered more liable to become diseased. Other causes act as 
pure excitants, as when there is a predisposition to a disease 
— e. g., eczema, and the local irritant excites it, but proba- 
bly would not if acting without the existing predisposition. 
Some influences, however, are really producers of disease, as 



58 THE CAUSES OF SKIN DISEASES. 

in the case of medical irritants, or circulated poisons — e. g., 
malignant pustule, or parasites. Other agencies again only 
aggravate existing disease, as in the case of the wearing of 
flannel, or exposure, or scratching. 

In reference to the second point, it is indisputable that, in 
most cases, several agencies or influences, external or in- 
ternal in origin or operation, combine to make up the true 
cause of a disease, and it is the duty of the physician to re- 
cognize this fact and analyze very carefully the composite 
cause of skin troubles. In fact, in such correct analysis lies 
the source of all successful dermatological treatment. From 
a therapeutical point of view, diseases of the skin are very 
different things as portrayed on paper and as seen in the 
consulting-room. A disease may answer most perfectly to 
the typical description, but the remedies ordered for its cure 
may signally fail, because the analysis of its causation is in- 
correct or incomplete, or some coexistent condition which 
exerts an antagonistic action to the operation of the remedies 
prescribed may have been overlooked, as is the case when 
neglected constipation so often defeats the proper action of 
tonics. Diseases are greatly modified as they occur in differ- 
ent subjects, and it is not the uncomplicated type that is to 
be dealt with in practice, but the disease modified and in- 
fluenced by the many concomitant conditions of age, consti- 
tution, occupation, etc. 

It may be useful to mention a few common combinations 
met with clinically, which illustrate the multiform character 
of the causation of skin diseases, as seen in the consulting- 
room. In the case of eruptions provoked by local irritants, 
referred to above, there is very frequently debility present 
in those who are attacked by these eruptions. This debility 
favors the development and tends to promote the chronicity 
of the disease, and must be removed if the eruption is to get 
well, and if it is to be cured in the best way possible. In 
fact, the skin of a healthy person will resist the action of 



THE CAUSES OF SKIN DISEASES. 59 

many of the local irritants specified, but the skin cannot do 
so if the subject be weak and debilitated ; so that it is an 
important point to give tonics as the rule in cases of erup- 
tions excited by local irritants. This simple combination of 
causes, debility and local irritants, is often found to induce 
erythema, eczema, lichen, etc. Other examples of concur- 
rent causes must readily occur to the reader, such as eczema 
in a gouty subject, modified by neglect and scratching ; 
pso?*iasis in a strumous subject, in whom the tendency to 
the disease is hereditary ; erythema in a rheumatic subject, in 
connection with dyspepsia ; eczema occurring in cooks ex- 
posed to the irritating influence of the fire, whilst the patient 
also has a blood current charged with retained excreta, in 
consequence of inefficient bowel and kidney action ; lupus 
in a scrofulous subject ; tinea tonsurans in a boy with per- 
sistent anemia and a phthisical tendency ; pruritus in con- 
nection with senile atrophy of the skin, liver derangement, 
gout, or it may be in connection with diabetes. Indeed, ex- 
amples might be multiplied almost indefinitely. 

In estimating therefore the cause of any given cutaneous 
disease, attention must be paid not only to predisposing and 
exciting causes, but to coincident occurrences and accidental 
concomitants which modify such disorder ; for it is not in 
the abstract that the disease is to be regarded, but in its en- 
tirety, and in all its clinical features and behavior. The 
correct estimation of a disease after this fashion constitutes 
the true diagnosis, upon which a few remarks will be made 
in the next section. 



60 DIAGNOSIS. 



SECTION V. 



DIAGNOSIS. 



Firstly — In making a diagnosis the observer should apply 
the important rules laid down (Section I.) for examining 
skin diseases — that is to say, he should examine the whole 
of the eruption and not a part only, and also trace carefully 
its history, to discover the nature of its beginning, the cha- 
racter of its stages, if any, and their transitional relation- 
ships, and the general course of the eruption up to the time 
of observation. 

Secondly The observer must proceed to determine to 

which class the disease belongs, according to the principles 
laid down in the chart in Section III. He should inquire 
in the first place whether the eruption belongs to one of the 
Acute Specific Diseases. If this be so, then the constitu- 
tional condition will be by far the most pronounced, the 
patient more or less prostrated, the temperature unusually 
high, whilst other pyrexial symptoms will be marked and 
out of proportion to the mere rash ; the access of the malady 
will have been comparatively sudden, and so on. If the 
eruption be essentially erythematous, then it must be one of 
four conditions — viz., erythema, intertrigo, roseola, or urti- 
caria. Is the disorder accompanied by sero-purulent dis- 
charge, by the development of bulke, by pustules, or by 
squamae alone ? Then the disease is one of those comprised 
under local inflammations. Is the eruption part of a cachexia, 
or some special diathetic condition present ? Then it be- 
longs to Group 2. And in like manner Hypertrophies or 
Outgrowths of Tissue, Atrophies. New Formations, Hemor- 
rhagic Spots, Neurotic conditions without organic changes, 



DIAGNOSIS. 61 

Pigmentary Alterations, Parasitic Diseases, and Affections 
of the Glands, Hair, and Nails will be put under their re- 
spective groupings. In the case of New Formations, the 
diagnosis is singularly easy. The youngest student can 
readily distinguish the newly -formed fleshy mass of a neo- 
plasm in the skin from the ordinary, rapidly-formed, semi- 
hypersemic, inflammatory deposit of a similar size ; and he 
knows practically that he has a case of syphiloderma or 
lupus to deal with. Further, in making a diagnosis, the 
observer must remember to determine whether the disease is, 
or is not, complicated by another, as evidenced by an ad- 
mixture of different characters, and to thoroughly sift out the 
nature of any constitutional modifying influences. 

Thirdly. — An estimate of the immediate or exciting cause 
of any given eruption is of the first importance in a com- 
plete diagnosis. No doubt, when the observer has been able 
to put the disease before him into its proper class, a pretty 
correct indication is obtained of its causes, especially as re- 
gards Classes 1, 2, 4, 5, 6, 9 (Section III.) ; yet, unfor- 
tunately, the difficulty is greater with the eruptions of the 
commonest occurrence, comprised in Class 3, or the local 
dermal inflammations, and with those in Classes 7, the Neu- 
roses, and 10, the gland and hair disorders. Hence the 
observer must proceed on the lines laid down in Section IV., 
working out the specific cause, and inquiring into the pro- 
duction of the eruption from within or without. His object 
is to seek for the source in (see Section IV., A) an heredi- 
tary tendency, a condition of blood poisoning, nervous disturb- 
ance, a disposition in the tissues themselves to take on a 
diseased condition, or perhaps some climatic influence. If 
not, then the cause is to be sought for in local agencies as 
detailed under B (Section IV.). And at the same time the 
observer should bear in mind what has been said about the 
multiple character of the causes of skin diseases. By attend- 
6 



62 TREATMENT. 

ing to these several points the diagnosis will be worked out 
correctly and with facility. 



SECTION VI. 

GENERAL PRINCIPLES OF TREATMENT. 

If, as has been already stated, there is nothing essentially 
special in the pathological changes that occur in skin dis- 
eases, it follows that there can be little that is absolutely 
special in the treatment. The minor differences that do 
exist, arise from the fact that the skin can be irritated 
directly, and that the diseased parts become rapidly dry, 
harsh, cracked, etc., from the constant exposure to the air, 
so that they need to be kept protected and supple by the use 
of moistening applications. Otherwise the general princi- 
ples of therapeutics are applicable to the case of skin mala- 
dies, and it is necessary for the reader to mentally lay firm 
hold of this fact. 

A correct diagnosis must of course precede successful 
treatment. When in accordance with the rules already laid 
down a given disease has been placed in its proper clinical 
class, and the exciting and other causes discovered, the 
proper kind of treatment naturally suggests itself. 

It may be said, indeed, that the ten groups of skin dis- 
eases require three main methods of treatment — viz., a 
purely local one ; one almost wholly general ; or a mixed 
kind, i. e., one partly local and partly general. That is, in- 
deed, saying in other words that skin diseases are made up 
of those which are essentially local in nature, those essen- 
tially general, and those more or less local in their main 
features, but influenced by general conditions. In the first 
category may be placed Groups 4, 5, and 9, viz., the hyper- 
trophic and atrophic, the neoplasmata, and parasitic diseases; 



TREATMENT. 63 

in the second Groups 1 and 2, the eruptions of the acute specific 
diseases, and the local manifestations of diathetic diseases ; 
and in the third Groups 3, 6, 7, 8, and 10, viz., local in- 
flammations, hemorrhagic, neurotic, pigmentary disorders 
and most of the glandular disorders. 

In dealing with the diseases in the first category, viz., 
Groups 4 and 5, absorbent or astringent remedies to promote 
resolution, or removal by caustic or surgical means, consti- 
tute the treatment. In Group 9, parasiticides are to be em- 
ployed to kill the insect or fungus which produces the 
particular disease present. In dealing with the components 
of the second category, viz., Group 2 — for we need not touch 
on Group 1 — specific remedies are used : in scrofuloderma, 
cod-liver oil ; in syphilis, mercury and iodide of potassium ; 
in leprosy and framboasia, hygienic measures and so-called 
" specifics." So far all is clear. 

When we come to the third or mixed class, or category, of 
cases indicated above, the principles of treatment are more 
varied. Groups 6, 7, 8, and most of the diseases comprised 
in 10 — for some must be dealt with as local inflammations — 
are consequent on what may be conveniently termed debility, 
and the treatment consists of the use of general tonics, etc. 
It is not necessary here to add more about them, as they are 
among the more infrequent of skin maladies. As regards, 
however, Group 3, viz., local dermal inflammations and cer- 
tain of the components of Group 10, such as sycosis and 
dysidrosis, the case is different, for the diseases comprised 
in it contain, as will be seen at a glance, almost all the ordi- 
nary forms of skin diseases, and it is amongst these the 
greatest difficulties are met with, owing to their many causes 
of excitation, aggravation, and modification. Now the dis- 
eases comprised in this Group 3, are essentially inflamma- 
tory, but some run a course of definite duration, as in herpes 
and roseola, and hence require only watching to prevent in- 
tercurrences ; or for the alleviation of special symptoms and 



64 TREATMENT. 

conditions, such as pain or disfigurement. The majority, 
however, run an indefinite course, and are to be attacked by 
therapeutic measures, based upon a consideration of the 
varying combination of exciting, aggravating, or modifying 
agencies. The treatment, therefore, of the components of 
Group 3, and those of Group 10, before specified, consists in 
a careful combination of both local and internal remedies. 

As regards local remedies, there are three main rules to 
be observed, viz. : — 

(1) Whenever active hyperemia is present, be the disease 
what it may, applications of a stimulating nature should not 
be used, but the treatment should be essentially soothing, 
otherwise the inflammatory symptoms will be increased, and 
the disease aggravated and probably spread. The vessels, 
especially in the earlier stages of congestive diseases, are 
very sensitive to stimuli — and they readily contract and dilate 
under their influence. The tonicity of these vessels is soon 
lost with any great increase of dilatation, and its conse- 
quences, under these circumstances, whilst the area of the 
congestion is widened by the sympathetic action of the irri- 
tants upon the parts in the neighborhood of the original seat 
of disorder. Soothing remedies have contrary effects. 

(2) The action upon the skin of all external irritants — 
such as scratching — should be prevented, and the air even 
excluded from inflamed or excoriated surfaces, especially by 
oil- packing. 

(3) Not until the stage of active hyperemia has fairly 
passed should astringents, stimulating applications, or revul- 
sives be employed. These, and absorbents, are to be re- 
served for the stages of vascular sluggishness and inflamma- 
tory induration and thickening, when not only the capillaries, 
but the lymphatics require stimulation with a view to pro- 
mote the absorption of morbid products. 

As regards internal or general remedies, it is proposed to 
indicate below, in as practical and concise a form as possible, 



TREATMENT. 65 

the conditions which should be taken into consideration in 
framing the treatment of such diseases as erythema, inter- 
trigo, urticaria, eczema, lichen, prurigo, pemphigus, hydroa, 
ecthyma, furunculus, pityriasis rubra, and psorias ; and 
inflammatory conditions of the glands and hair follicles, 
such as acne, dysidrosis, and sycosis, which are analogous 
in pathological nature to, and only differ in regard to their 
anatomical seat from, those preceding. The following short 
sketch or chart, inasmuch as it applies to the great majority 
and most common forms of skin diseases, should be used 
regularly in determining the treatment, which must neces- 
sarily vary with the different combinations of influencing 
agencies referred to. 

We may observe that we invariably mentally employ this 
analytical chart or summary in dealing with cases of in- 
flammatory skin diseases in our consulting room. Having 
first determined by inspection and interrogation the general 
origin, course, and symptoms of a disease — that is, having 
made a bare diagnosis, we proceed to discover the presence 
and degree of influence of one or many of the several modi- 
fying conditions which we are about to notice briefly in 
detail ; and then we prescribe not only the treatment appro- 
priate to the disease itself in the abstract, but so modified or 
amplified as to meet the necessities of each case in regard to 
the existence of any of these special conditions. We desire 
to treat the patient's disease in the light of the patient's 
pecularities, and the success of treatment so formulated is 
ample testimony to the importance of the rule laid down. 

The conditions here referred to are : — 

A Syphilitic Taint. — This tends to induce induration 
from the presence of syphilitic tissue ; or it leads to ulcera- 
tion, cachexia, and general debility — features which are 
unusual in the diseases which they complicate. This taint 
is sometimes in operation in cases of eczema, psoriasis, pem- 
phigus, ecthyma, acne, and intertrigo (of infants). 

6* 



60 TREATMENT. 

Constipation — This causes dyspepsia, liver torpor, and 
retention of excreta, and so leads to an impure blood current, 
by which eruptions are aggravated, and to debility. It 
occurs, of course, in all forms of skin diseases, and it is im- 
possible to overrate the importance of attention to it. Con- 
stipation, besides leading to an aggravation of existing 
eruption, prevents the due exhibition of remedies, as in the 
case of many tonics, which can often be given in combina- 
tion with aperients, but not otherwise, since, by their con- 
stringing effect, they, when unaided by aperients, give rise 
to dyspepsia, headache, and other symptoms. We mention 
these facts because they are of such frequent application in 
dealing with skin troubles. 

Debility, including anaemia This retards recovery from 

want of recuperative power in the system ; but frequently, 
important emunctory and assimilative organs perform their 
functions languidly or imperfectly as a consequence of the 
debility ; and so, as a consequence of the retention of un- 
oxidized or effete products, the blood becomes charged with 
irritating materies morbi. It is especially operative in 
furunculus, eczema, psoriasis, lichen, pityriasis rubra, 
pemphigus, urticaria, and ecthyma. 

Diabetes This increases inflammatory conditions, favors 

the occurrence of phlegmonous inflammation, and leads to 
freer development of disease, and tends to chronicity of 
eruption. Its influence is often seen in eczema, psoriasis, 
intertrigo in adults, furunculus, and anthrax. 

Dyspepsia — This induces debility. It also leads to liver 
disturbance, and impurification of the blood ; and it increases 
hyperemia by reflex action, as in acne. It is common in 
connection with eczema, urticaria, acne, and sycosis. 

Errors of Diet — These introduce special irritative sub- 
stance into blood, cause dyspepsia, lead to accumulation of 
nitrogenous matters in system, to liver disorder, etc., and are 



TREATMENT. 61 

operative in all forms of inflammatory eruptions without ex- 
ception. 

Gouty and Rheumatic Diatheses — These cause accumu- 
lations of uric and lactic acids and allied compounds in 
the blood, which give an inflammatory character to disease. 
They influence especially eczema, psoriasis, lichen, ecthyma, 
sycosis, and urticaria. 

Lack of Hygiene This disposes to torpor of skin. It 

favors the occurrence of morbid action and disease, and 
greatly influences acne, sycosis, eczema, intertrigo, and 
erythema. 

Repression of the special normal eliminatory functions. 
This throws the necessity of compensatory elimination on 
the skin, which may fail to respond, and so become diseased. 
It favors increase of fluid in the tissues of dependent parts. 
It occurs in furunculus, ecthyma, acne rosacea, and eczema. 

Retention of Excreta, from kidney, liver, and bowel in- 
activity. This, a most fertile source of skin irritation, which 
it both excites and increases by leading to the accumulation 
of effete products or materies morbi in the blood, gives the 
blood an irritative quality, which aggravates hyperemia in 
all inflammatory skin diseases. It is a common cause of 
pruritus of the skin. It also leads, in the case of kidney 
torpor, to increase of watery fluid in tissues, as in eczema of 
the legs. 

Strumous Diathesis This imparts an unusual purulent 

character to eruptions, and favors the implication of the 
connective tissues. It operates powerfully and commonly in 
cases of eczema, psoriasis, acne, and sycosis. 



PAET II. 

THE DETAILED DESCRIPTION OF CUTANEOUS 
DISEASES, ARRANGED IN THEIR ALPHA- 
BETICAL ORDER. 

Acne. — This disease is an inflammation of the sebaceous 
glands, the ducts of these glands, and the periacinous fibro- 
cellular tissue to a varying degree. The upper part of the 
hair-follicle, into which the glands discharge, becomes neces- 
sarily involved in the inflammation. 

The varieties of acne are said, commonly, to be four in 
number, viz., Acne punctata, A. simplex or vulgaris, A. 
indurata, and A. rosacea, but the latter is a compound of 
acne and hyperemia of the face tissue generally. The first 
three of the four forms of acne arise directly from accumu- 
lation of sebum, more or less altered perhaps in quality, in 
the glands and their ducts. But besides these varieties, 
there are unusual or artificial phases of acne produced by 
the special irritation or stimulation of the glands by certain 
medicinal substances, including iodide and bromide of potas- 
sium when taken internally, and- tar when applied exter- 
nally. Acne of a special kind is also induced by the syphilitic 
poison in action upon the skin, and lastly there is a peculiar 
acne incident to a low condition of health, to which Hebra 
has given the significant term acne cachecticorum. 

Acne in the commoner varieties, as we have already indi- 
cated, results immediately from the retention of sebum, the 
retained plug which is discolored by dirt, being designated 
comedo. It is important to point out certain special con- 
ditions, which favor the retention or non-excretion of the 



70 THE DETAILED DESCRIPTION 

sebum in acne. These are three ; the first is inactivity or 
torpor of the skin ; the second is undue production of seba- 
ceous material ; and the third is the formation of sebum of 
greater consistency than usual. This last is practically the 
most important of the trio ; for without this tendency acne 
would be uncommon. The disposition to the secretion of 
sebum of a less oily or more fatty character is met with in 
lymphatic and strumous subjects, especially about the time 
of puberty, when the hair follicles and their attached seba- 
ceous glands are in a state of physiological activity in con- 
nection with the free formation of hair, and are, in conse- 
quence, easily disposed to become the seat of disorder. The 
sebaceous plug, or comedo, which is the early and first sign 
of acne, may exist without much attendant change in the 
gland-wall, or tissue around the latter ; but as a rule it soon 
undergoes a chemical change, whereby the sebum acquires 
an acrid character, and thereby induces irritation and inflam- 
mation, which vary in extent and character according to 
the constitutional bias of the individual, and acne results. 
Acne, therefore, is a follicle plugged by an augmented sebum 
with a varying degree of attendant follicular and peri-follicu- 
lar inflammation. 

It should be mentioned here that ordinary acne attacks 
certain localities by preference, such as the face and the 
shoulders, but artificial, or syphilitic, or cachectic acne is 
more or less general in its attack. 

We now proceed to give a brief description of each va- 
riety of acne. 

Acne punctata In this form there is simple retention 

of more or less inspissated sebum forming comedo, whilst 
there is no decided inflammation of the follicle, but only a 
certain amount of prominence sufficient to form a pimple. 
It is common on the face, the shoulders, and front of the 
chest, and appears on young people of lymphatic and stru- 
mous temperament. The minute, discolored plug of sebum 



OF CUTANEOUS DISEASES. H 

may be readily squeezed from the follicle, and looks like a 
little grub. 

Acne simplex or vulgaris is that form in which slight 
perifollicular inflammation and occasionally suppuration are 
added to the phenomena of retention of sebum or plugged 
follicles. It is an exaggeration of, or an inflamed, acne punc- 
tata, and occurs under similar circumstances. Comedones 
are found intermixed with the inflamed acne spots. 

Occasionally acne is confined to the forehead and the re- 
gion of the temple almost exclusively; it may assume the 
simple form, but now and then the pustules are flattish and 
more or less umbilicated, and after crusting they disappear 
and leave distinct scars behind, something like those of 
smallpox. This form is often obstinate, and is apt to recur. 
In some cases the scalp is also affected by similar spots 
seated at the hair follicles, and scattered more or less gene- 
rally over the scalp, especially over the top and front parts. 
In consequence of the umbilication of the spots, the term 
acne varioliformis is applied to this phase of acne. It is 
not certain whether it is not syphilitic, at least syphilitic 
treatment is very efficacious with it. We reserve our opinion 
as to its exact nature. The term acne varioliformis has 
been also applied to molluscum contagiosum. 

Acne indurata is a more severe form of the disease. It 
is characterized by the large size of the spots, and by their 
possessing considerable inflammatory induration at their 
bases, together with a certain amount of pain, lividity or 
violet-redness, followed by suppuration, and, it may be, 
crusting. The spots may be painful, and, when large, they 
leave pits or scars after their disappearance. It occurs in 
the same situations as the other two phases of acne, but it is 
altogether more severe and extensive. In some cases the 
acne spots are very much indurated and as large as full-sized 
peas, or even larger. 

Acne rosacea is characterized by its bright red color, more 



*I2 THE DETAILED DESCRIPTION 

or less formation of Dew connective tissue about, with hyper- 
trophy of, the glands ; and by its occurrence in middle-aged 
persons oftentimes the subjects of menstrual disorder. The 
condition denominated acne rosacea, and called gutta rosea 
by Wilson, or simply rosacea by others, is, as stated before, 
scarcely a true acne. It consists of chronic hyperemia of 
the face, attended mainly by the formation of red papules, 
due to effusion of lymph into the papillary layer of the skin. 
These papules show out from the general reddened surface 
as minute elevations like non-suppurating acne spots, and 
they present no central opening. The occasional presence, 
however, or intermixture of a certain number of true acne 
spots leads to the inference that the disease is really acne, 
whereas it is a mixed condition. 

The hyperemia present in the above described varieties of 
acne is especially intensified by dyspepsia, by errors of diet, 
and by local irritants. The inflammation, too, is modified 
by the strumous and syphilitic cachexia?, which conduce to 
implication of the surrounding cellular tissue and to suppu- 
ration in struma, and to induration and ulceration in 
syphilis. 

As regards unusual forms of acne a few words may be 
added here : — 

Tar acne. — The use of tar to the skin externally is often 
followed by stimulation of the sebaceous glands, and the pro- 
duction of an acne-like eruption, but it has this peculiarity 
that the tar collects in minute amounts in the follicular orifices, 
so that the punctate points are black or treacly in aspect. 

Bromide and iodide acne A description of these will be 

found under the head respectively of Bromide and Iodide 
eruption. The disease presents the aspect of acne vulgaris 
or acne indurata of bright color. It is specially characteristic 
of these forms that they do not attack the face only, but many 
different regions of the body ; such as the back, the forearms, 
the lower limbs — a fact which should always excite suspi- 



OF CUTANEOUS DISEASES. 73 

cion as to the cause of the acne. They alike appear and dis- 
appear with the exhibition . or withholding of these drugs. 
Syphilitic acne is widely distributed, it is attended by ulcer- 
ation of the acne spots, and forms part only of a series of 
syphilitic phenomena. 

Cachectic acne occurs as a general acne in badly nourished 
or half-fed or scorbutic subjects. It is indolent, painless, of 
livid hue. It does not ulcerate, whilst the skin which it 
affects wears an unhealthy or cachectic look. 

The differential diagnosis of acne is simple. The plugged 
follicle constituting comedo, and the simple forms of acne 
{acne vulgaris) are not liable to be mistaken for any other 
disease, for the comedones are peculiar to acne alone. Acne 
indurata and acne rosacea may be thought at times to be 
syphilitic, and may resemble hydroa, but syphilitic acne is not 
confined to the face or shoulders ; it ulcerates, and is attended 
by other readily recognized syphilitic phenomena. Acne in 
strumous subjects ulcerates and leaves pits, but it is a uni- 
form eruption, and not multiform or corymbose like syphi- 
litic rashes ; it attacks the ordinary seats of acne, and it is 
made up of indolent, livid, boggy -like indurations. Hydroa of 
the face may consist apparently of little indurations like acne 
indurata, scattered here and there, but they tend, if not 
scratched, to vesiculate ; they have no comedo, that is, they 
are not follicular, but dermic in origin, and they are very 
pruritic, even from their earliest stage. 

Treatment — The objects in view in the case of the com- 
moner varieties of acne, which we deal with alone here, are 
— -first, to promote the loosening and removal of the plugs 
of sebum from the follicle (in comedo especially) ; secondly, 
to lessen the hyperemia ; thirdly, to restore tone to the ves- 
sels and to the general system ; and, fourthly, to promote the 
absorption of inflammatory products. We now proceed to 
consider the several varieties of acne. In acne punctata 
the skin will often bear a good deal of stimulation with ad- 
1 



74 THE DETAILED DESCRIPTION 

vantage, and hot water bathing with friction with mild soap 
and the use of an alkaline wash (45), or a weak alkaline 
pomade may be employed, or if this fail (67), cautiously 
used, and tonics, constitute the proper treatment, as the rule 
(see Comedo). In acne simplex it is necessary in the first 
place to remove dyspepsia, if present, by (97) before giving 
tonics such as (90), (107), or (108), or in anaemic subjects 
(94). Cod-liver oil should be prescribed in the strumous. 
Occasionally there is a loaded state of system, which is im- 
proved by diuretics, especially if the face is much congested, 
and the urine be scanty and loaded with urates. Locally the 
affected parts should be bathed with hot water twice a day, 
and soothed with (14) or (74), to reduce the hyperemia, and 
presently stimulated with (64) or (66) diluted. In acne in- 
durata similar internal remedies are required at first ; or if 
the system be loaded (96) or (98) ; if there is much indura- 
tion (85). In gouty subjects a little colchicum wine — 5 
drop doses — with a carbonate of magnesia and bitter infu- 
sion mixture will often be of value in the earlier congestive 
stages. Locally, it is best to soothe, as in acne simplex, and 
subsequently to remove the induration by the use of (47), 
(60), or (66) ; or, if necessary, each spot may be occasion- 
ally touched with acid nitrate of mercury. In acne rosacea 
it is necessary first to look to the state of the uterine func- 
tions, to remedy coexisting dyspepsia, debility, tippling 
habits, etc. Internally (95) may be given with advantage; 
locally (74) may be used, with the occasional application of 
acid nitrate of mercury to each spot, or (80) may be applied 
each night to very decided indurations. In some cases it is 
advisable to cut the vessels across with a lancet, and to ap- 
ply collodion regularly for awhile, and after the parts have 
bled, to allay irritation or excessive hyperemia in the first 
instance. This may be followed by (Q5) which is a very 
effective remedy. In indolent cases of extensive acne rosa- 



OF CUTANEOUS DISEASES. 75 

cea and indurata (65) may be used every night or every 
other night. 

Alopecia signifies Baldness, and may be partial or 
general : it is either idiopathic, i. <?., the sole diseased con- 
dition present ; or symptomatic, i. e., a secondary conse- 
quence of some other morbid state. When symptomatic, 
the baldness is usually a relative one, that is to say, it is 
rather a general thinning than actual total loss of hair in the 
affected part, and this form results from the disturbance of 
the nutrition of the part by inflammatory diseases — e. g., 
eczema ; or by blood diseases — e. g., syphilis ; or by para- 
sites {see Tinea) ; or it is the consequence of general debility 
from other special cause. When idiopathic, baldness is 
usually complete in the part affected, and it is ascribed to 
atrophy of the affected parts, and failure in the re-formation 
of hair ; but this failure or atrophy is itself often the conse- 
quence of general debility connected with the too rapid 
growth of young people. This form of alopecia usually 
takes the form of circumscribed areas of decided baldness 
{areata or circumscripta) which gradually extend in size and 
increase in number ; at times the entire hair of the scalp, or 
even of the body, is lost, and that rapidly, but this is a com- 
paratively infrequent occurrence. The skin in this alopecia 
is white. It is also less vascular and less sensitive than usual. 
This form of baldness is to be distinguished from baldness 
the result of the attack of parasitic fungi upon the hair. 

Treatment In symptomatic cases the treatment of the 

secondary alopecia is that of the disease which induced it in the 
first instance, with local stimulation subsequently. In the 
idiopathic forms, where the entire hair is lost, little can be 
done save by continuous stimulation and attention to the 
general health. When more localized, however, good may 
always be effected by applying tincture of iodine daily for 
two or three weeks, or rubbing in an ointment composed of 



16 THE DETAILED DESCRIPTION 

two grains of bichloride of hydrargyrum to one ounce of 
lard, for a fortnight or so, and especially around the edges of 
the bald patches ; then, or when minute downy hairs appear 
(129), or better (130), may be infricted with perseverance. 
At the same time appropriate tonics are to be prescribed, 
should there be anaemia or debility. 

Anthrax or Carbuncle is a phlegmonous inflamma- 
tion of the' skin, with necrosis of the cellular tissue and in- 
dolent suppuration, the necrosed tissue forming many cores 
over the surface of the carbuncle, and being discharged, to- 
gether with pus, through the several corresponding apertures. 

* 

The surrounding parts are brawny, reddened, and indurated, 
and the vessels plugged. Carbuncles are painful, and ex- 
haust by their irritation and accompanying discharge. Ex- 
tensive sloughing and ulceration may occur, and even pyaemic 
symptoms. Their most common seat is on the back or back 
of the neck, and they may occur singly, or one or two to- 
gether. The subject of them is usually much depressed in 
health, and occasionally of a diabetic habit. 

Treatment consists in the application, in the early stage, 
of caustic potash, which we prefer, or the employment of a 
subcutaneous, or other free, crucial incision, with subsequent 
pressure and careful dressing. 1 Internally) the greatest atten- 
tion should be paid to sustaining the strength of the patient, 
by food, medicines, or. stimulants, as the case may require. 

Area, see Alopecia. 

[ l The subcutaneous injection of carbolic acid into several points 
of the affected area, has been followed, in some cases, by very sat- 
isfactory results. The systematic application of adhesive strips so 
as to make pressure around the periphery of the carbuncle, with 
an emollient poultice covering its centre, is also highly recom- 
mended. — Ed.] 



OF CUTANEOUS DISEASES. 77 

Atrophia Cutis, or atrophy of the skin, occurs under 
a variety of circumstances. It may be either a primary 
condition, or appear as a secondary phenomenon in other 
disorders. The secondary aspects are observed in a more 
or less localized form, in connection with the development 
and growth in the skin of neoplasmata, e. g., the lupoid and 
the syphilitic : as a result of ulceration of all kinds in the 
skin, as in variola, ecthyma zoster; after traumatic injuries, 
etc. ; and in a more general form atrophy of the skin results 
in certain cases of scleroderma, the simplest forms of ich- 
thyosis, and senile decay. But the term atrophia cutis is 
more strictly applicable to primary conditions which may be 
congenital, but are usually acquired. 

Hebra and Kaposi and E. Wilson have described, under 
the names respectively of Xeroderma and General Atrophia 
Cutis, a peculiar thinning and shrinking of almost the entire 
skin of the body, which it is very difficult to distinguish by 
words from the atrophic form of Scleroderma. It is so very 
rare that we refer the reader for details to the accounts of 
these observers. 

A more frequently met with but far from common form of 
idiopathic atrophy is the so-called Linear Atrophy or Strice 
et Maculae Atrophice Cutis. It assumes the aspect of bands 
or lines of thinning and wasting of the skin. 

This linear atrophy is met with in the form of white or 
pinkish, shining, smooth or finely-reticulated, scar-like 
streaks or bands from half an inch to two inches broad by 
several inches long. They are depressed below the sur- 
rounding surface, and the skin is thinned so that the striae 
are sometimes of a deep pink or even claret color. They 
are arranged close to one another in more or less parallel 
curved lines, and sometimes they are somewhat spiral. 
They occur most frequently near the anterior brim of the 
pelvis, over the gluteals, near the trochanter, on the thigh, 
and on the arms. We have recently met with a beautifully 



78 THE DETAILED DESCRIPTION 

symmetrical case occurring in the iliac regions, associated 
with the macular form on the thorax and shoulders. Usually 
their long axis does not correspond exactly with that of the 
limb or with the course of the nerves, but Mr. Wilson has 
recorded a case in which this existed. 

The macular forms are similar in nature, and many are 
extremely like the abdominal marks in pregnancy, but they 
are round or oval, or in lines. They vary in size up to that 
of half a crown. Dr. Liveing has lately described a primary 
red hypertrophic stage to this form of linear atrophy, the 
occurrence of which he states is overlooked, and he objects 
therefore to this disease being considered a pure atrophy of 
the cutis. We have observed this stage ourselves. 

The exact etiology of this affection is very obscure, but it 
seems to depend on the cessation of the trophic nerve-influ- 
ence in localized areas. The usual want of correspondence 
of the patches with the distribution of the nerves has been 
already referred to. 

Kaposi has examined into the anatomy, and finds the epi- 
dermis atrophied, the papillae disappeared, the bundles of the 
corium thin, the bloodvessels few and small, the sebaceous 
glands and hairs atrophied, and the fat gone from its frame- 
work. 

Lanceolate broad stripes sometimes occur in Morphoza 
and Scleroderma, which are indistinguishable from linear 
atrophy, and such is the case also with the macular form. 
These latter are to be distinguished from the abdominal 
marks of pregnancy and from the marks caused by the dis- 
tension of the skin by any tumors, etc. The marks are pro- 
duced in these cases by the atrophy following a rupture of 
the deeper layers of the corium and subcutaneous tissue, and 
they are preceded by the signs of a ruptured vessel. The 
limited cicatrices left by destruction of tissue can hardly be 
a cause of confusion. 

Treatment In the idiopathic form all that can be done 



OF CUTANEOUS DISEASES. ?9 

is to endeavor to induce a more active nutrition in the part 
affected by gentle stimulation, and to build up the health by- 
general tonics, etc. 

Bakers' Itch is a term which includes lichen agrius 
and chronic eczema of the hands. It is induced by the irri- 
tant action of the flour used by bakers, in debilitated subjects 
especially (see Eczema). 

Treatment Patients are often considerably out of health, 

and have a loaded system, though they are debilitated. For 
such (95), or even (96), are to be given, and these may be 
followed up by tonics, such as (94) or (108). Locally the 
part may be first soothed by (76), or the linimentum calcis, 
or, if very itchy, by (40) or (42), and afterwards, when the 
inflammation is subdued, (69) or (78) may be employed. 

Baldness, see Alopecia. 

Barbadoes Leg, see Bucnemia. 

Boils, see Furunculi. 

Bricklayers' Itch is similar to bakers' itch, only that 
it is excited by the irritation of lime. It requires similar 
treatment to bakers' itch. 

Bromide of Potassium Eruption The bromides, 

but particularly the potassium salt, in certain cases, even 
when only given to the extent of a few small doses, produce 
eruptions on the skin, which are essentially acneiform in 
character. The rash may resemble acne vulgaris in general 
aspect and situation, but usually, if not at first at least after 
awhile, the limbs or the chest, and even the scalp, are affected. 
It has always seemed to us that the skin is dirty and greasy- 
looking in persons suffering from bromide eruption. In some 



80 THE DETAILED DESCRIPTION 

cases the acne is more like well-marked acne indurata or 
ecthyma, since the cellular tissue about the sebaceous glands 
is more or less actively implicated in the inflammatory mis- 
chief about them, and in that case the base of the pustules is 
hard, tender to the touch, and somewhat painful. In place 
of any true comedos there is a collection of milky-looking 
fluid at the apices of the spots, which is very characteristic 
to those who have learned to recognize it. But there are 
severer aspects of bromide eruption. Occasionally oblong 
or roundish, softish, nodular, pinkish or bluish-red swellings, 
varying in size, appear about the face and neck, or extremi- 
ties, perhaps any one or two appear at one time. In the 
early stage they seem to be dotted over with yellowish points, 
indicative of milky or cream-like fluid, really altered sebum, 
confined beneath the cuticle. These nodules sometimes dry 
away and crust over, but they may become large, and as- 
sume after awhile the apect of a thickly dark-crusted impe- 
tiginous patch or approach the aspect of rupia, after giving 
exit to a cheesy smegma, perhaps, which is altered sebum 
mixed with pus. In some cases I have seen decided and con- 
siderable ulceration induced. The swellings are painful, and 
leave behind dark-lined stains, and it may be cicatrices. It 
is a noticeable feature that in the severer forms of the erup- 
tion there are transitional stages present, showing the early 
and neutrally acneiform character of the eruption,. as well as 
the later nodular and impetigo-like phase. The bromide 
spots originate in inflammation of one or many adjoining 
hair sacs and glands, the sebum being altered or increased in 
amount, the periacinous connective tissue being inflamed 
and indurated. The phases of the eruption are all due to 
variations in the number of gland sacs, the amount of dis- 
charge, inflammation, and crusting present in any given case. 
Neumann's microscopical observations are clear upon this 
point. 

The treatment consists, of course, in withholding the bro- 



OP CUTANEOUS DISEASES. 81 

mides from the affected individual, or, where this cannot be 
secured, in administering moderate doses of arsenic in con- 
junction with the bromide salt. 

Bucnemia tropica, see Elephantiasis arabum. 

Bug-eruption The attacks of bugs is a common cause 

of skin irritation in children, leading to pruritus and urti- 
caria, conditions which are intensified, or appear at night. 
The bug-bites may often be detected as rosy papules with a 
central punctum. The remedy is to get rid of the bugs from 
the rooms or beds, whilst the pruritus they induce may be 
relieved by alkaline baths (14), (23), (43). 

Caeotrophia follieulorum In the London Clini- 
cal Society's Transactions for 1868, Dr. Tilbury Fox has 
described and figured a disease resembling severe lichen 
pilaris ; that is to say, palish or reddish pimples seated at the 
hair follicles ; but in its severity is a deeper affection of the 
follicles ; in the fact of its being congenital, in its general dis- 
tribution in severe cases more or less over the body, and in its 
obstinacy to treatment, it is peculiar. It affects by preference 
the outer aspect of the arms above the elbow (producing there 
an appearance like a nutmeg-grater), but also the thighs, the 
trunk, and the sides of the face and forehead. The follicles 
are plugged by scales or exuviae, which can only be detached 
with difficulty ; the hairs are lost, or of the feeblest growth. 
The interfollicular portions of the skin are healthy. The 
disease is stated to occur in members of families where 
ichthyosis is common, and we have found this to be the case. 
The disease might well be regarded as a xeroderma of the 
follicles. The treatment consists in giving alkaline baths 
and rubbing simple oils or greasy substances into the skin, 
and exhibiting tonics internally, especially cod-liver oil. 



82 THE DETAILED DESCRIPTION 

Cancer, see Epithelioma and Rodent Ulcer. 
Carbuncles, see Anthrax. 
Chloasma, see Tinea versicolor. 



u j 



Comedones are the small black-topped sebaceous plugs, 
or accumulations of sebum, that are found in the early stage 
of acne punctata. Each separate, little black plug is called 
a Comedo. 

Treatment. — Writers recommend that comedones should 
be removed by free friction with or without some alkaline 
soap, and some have advised sand to be used. There are 
cases where the face will tolerate this rough usage, but as 
the rule in English practice only harm results therefrom. It 
must be recollected that the sebum plug tends to induce irri- 
tation, which is readily increased. We find it, on the whole, 
better in the bulk of cases to recommend the free use of hot 
water and the infriction of a mild carbonate of soda, or borax 
ointment for some few nights, to be followed by a calamine 
lotion, or, if the skin is irritable, the use of borax or alka- 
line washes (19), (45), and subsequently, when the skin is 
less irritable, tar soap or soft soap inunction cautiously, to be 
followed by (14), to allay irritation. Finally, it may be 
advisable to stimulate the glands to healthy action by such 
remedies as (65), (67), or (73). 

Condylomata, or "mucous tubercles," are small tumors, 
generally sessile, with a circular outline and somewhat flat- 
tened top, occurring as a part of syphilis. They are usually 
palish, reddish, or brownish in color, and spring up on mu- 
cous or cutaneous, or more often on muco-cutaneous surfaces, 
and especially about the anus. They are contagious and 
liable to suppurate, and contain the peculiar syphilitic tissue 
in their bases. The treatment locally is to keep them con- 



OF CUTANEOUS DISEASES. 83 

stantly clean and dry, and to apply astringents, or such mer- 
curial preparations as blue ointment, calomel powder, or a 
lotion of bichloride of mercury (gr. i-ij to Jj of water). 

Contagious Impetigo, see Impetigo contagiosa. 

Dermatitis exfoliativa, see Pityriasis rubra. 

Dysidrosis. — This affection is due to an inflammation 
of the sweat structures of the hands and feet, which was 
first described by Dr. Tilbury Fox in 1873, and is figured 
by him in his edition of Willan and Bateman's Atlas. The 
patient comes, as the rule, in severe cases, for advice with 
the hands held up to prevent their distension with blood, and 
wrapped up on account of their swollen, painful condition. 
This fact is an indication that the disease is clearly inflam- 
matory and painful. Dysidrosis is characterized clinically 
at the outset by a certain amount of tumefaction and redness 
of the part affected, and the rapid development or distension 
of the sweat ducts, which look like small sago grains imbed- 
ded, and at first not rising above the level of the skin. The 
sites affected, and generally symmetrically, are the sides 
and palmar aspect of the fingers, the palms, and often simi- 
larly the feet. There may exist also at the same time mili- 
aria of the general surface. Unless the attack is excessively 
mild the parts soon become decidedly reddened, tender, and 
swollen, and they itch and burn. As the collected fluid, 
which is at first acid as it issues from the patent orifices 
but rapidly becomes mixed with serum and alkaline, in- 
creases in amount, the vesicles get larger and project above 
the surface, and then become confluent, finally forming large 
bullge-like collections of fluid. The cuticle macerates and 
peels off, exposing a reddened hyperasmic surface, which, 
however, does not discharge like an eczema. The disease 
tends to run a definite course of 10-20 days, but the hand 



84 THE DETAILED DESCRIPTION 

may remain considerably inflamed for some time. There is, 
however, a great tendency to the recurrence of the affection. 
It may occur in winter, but more frequently in summer, and 
it especially attacks weakly persons who are the subjects of 
nerve debility. It is rarely that the patient is found other- 
wise than with a pallid look, and complaining of weakness 
and debility. 

Diagnosis — The diseases which dysidrosis may be con- 
founded with are eczema and pemphigus. It must be a very 
rare occurrence for eczema to be limited symmetrically to 
the hands (and feet), and especially to their palmar aspects. 
Moreover, dysidrosis lacks the prominent catarrhal features 
of eczema and the characteristic sero-purulent discharge. 
Pemphigus, with little or big bullae, sometimes occurs limited, 
at any rate for a time, to the hands, but rarely, if ever, to 
the palms. The history of the evolution of the bullae is quite 
different, the imbedded aspect of the vesicles in their early 
stage, which are seated at the sweat ducts, and the loculated 
appearance of the dysidrosis bulla are peculiar. It may be well 
to remind the reader that Mr. Hutchinson described in 1876 
a neurotic, symmetrical, bullous disease of the hands and feet, 
commencing like dysidrosis, which Dr. Tilbury Fox recog- 
nized as an exaggerated example of the latter affection, but 
Mr. Hutchinson, Dr. Liveing, Dr. Robinson, of New York, 
and others, do not regard it as a disease of the sweat appa- 
ratus. 

Anatomy. — Dr. Liveing regards dysidrosis as a " local 
hyperidrosis, consisting in an excessive secretion of perspi- 
ration, which, in consequence of its profusion and the con- 
gestion of the skin, which necessarily attends such an ex- 
cessive secretion, does not entirely escape through the sweat 
ducts, but leads to a general maceration of the cuticle and 
to secondary eczema." He adds, truly enough, that the 
sago-grain appearance of the vesicles might be presented by 
any little collection of fluid under such skin as exists on the 



OF CUTANEOUS DISEASES. 85 

palms and soles. Dr. Robinson examined microscopically a 
case which he considered dysidrosis, and he could find no. 
connection of the disease with the sweat ducts. Drs. Tilbury 
Fox and Crocker, however, in the last volume of the Clini- 
cal Society's Transactions have published an elaborate micro- 
scopic report upon portions of skin removed from a typical 
case in the earliest stage, and in which they thoroughly estab- 
lished the connection of the disease with the sweat glands, 
which had been concluded from clinical facts. They found all 
of the tissues very hypersemic, the sweat glands and ducts 
especially so, and exhibiting signs of inflammatory irritation. 
In the rete were found the vesicles filled with inflammatory 
products. They were in direct communication with the 
sweat ducts, and situated in the inter papillary portion. Dr. 
Liveing had stated his view before he had had an opportu- 
nity of seeing these specimens, which were exhibited to the 
Pathological Society only recently. 

Treatment — At first diuretics should be given, especially 
in gouty subjects or those in whom the urine is loaded or 
scanty, and these remedies should be followed up by suitable 
tonics, especially quinine and iron. A cool regimen should 
be adopted, hot drinks avoided, or whatever will increase the 
perspiration. Locally, if the body generally be affected with 
miliaria, alkaline baths may be prescribed, but the chief 
thing to do is to soothe the inflamed parts at the outset by 
wrapping them in some bland or oily substance such as Car- 
ron oil, and to subsequently use a slight astringent, as (76). 
In some cases patients affected by dysidrosis are very weak, 
and in such the disease may lapse into a semi-chronic state, 
and then a long course of tonic treatment, consisting of qui- 
nine, mineral acids, and nux vomica, must be adopted. 

Ecthyma. — This disease is characterized by the devel- 
opment of large isolated, painful, deep-seated pustules 
which have hard and inflamed bases. These pustules give 
8 



86 THE DETAILED DESCRIPTION 

rise to unhealthy ulcerations of a greater or less degree, and 
the crusts that form are large, dark, and firmly adherent. 
This disease occurs mainly in the badly nourished and ca- 
chectic. It may be excited by local irritants ; especially in 
children by acari and in elderly persons by pediculi. In 
fact, in the majority of cases ecthyma is a secondary occur- 
rence, as in scabies or phthiriasis ; nevertheless the pustules 
may be excited by scratching or irritants alone, and as a 
primary condition in the badly nourished. This is observed 
in those whose occupations subject them to the exposure to 
special irritants, such as the contact of lime to the skin. In 
syphilis ecthyma may occur, but here its pustules are asso- 
ciated with other well-marked syphilitic eruptions, whilst 
the surface is very dirty looking and ulcerates and scabs 
freely. 

Treatment If the ecthyma is secondary to scabies or 

phthiriasis these diseases must first be treated in the usual 
way and then tonics may be administered subsequently, 
when the ecthyma will disappear. It may be necessary to 
apply locally (35) or (60) to heal the ulcerations. If the 
ecthyma be idiopathic it will probably be desirable to give 
aperients and rectify existing cachexia or debility by good 
food and tonics, such as (92), (95), (103), with or without 
cod-liver oil, applying the local remedies mentioned above. 
If there be marked ulceration the sores may be cleansed by 
two or three applications of iodide of starch (52) or iodoform, 
and subsequently dressed with (28) or (81). 

Eczema is a simple inflammation of the skin character- 
ized in a typical case by redness, which is quickly followed 
by vesiculation and sero-purulent discharge which stiffens 
linen, and dries into thin, yellow crusts ; it is, in fact, a 
catarrhal inflammation of the skin. The disease begins by 
a serous effusion into the papillary layer, and the effused 
fluid finds its way into the rete, uplifts the cuticle slightly, 



OF CUTANEOUS DISEASES. 81 

so as to form papules, but these rapidly pass on to vesicula- 
tion. The fluid then escapes free upon the surface, thus 
constituting the discharge which continues a greater or less 
time. Coincidently with its escape, the fluid, which con- 
tains much fibrin, becomes more or less purulent, and there 
is a large amount of inflammatory cell-growth in the inter- 
stices of the stretched-out rete cells, and in the tissue of the 
papillary layer. If the disease becomes chronic, which is 
commonly the case, the cutis is altered by chronic inflamma- 
tory induration to a varying depth. Eczema, therefore, be- 
gins as a " serous catarrh," and is followed by suppuration 
and inflammatory infiltration into the skin. The disease is 
always attended by more or less itching. 

Some think that eczema does not necessarily discharge. 
It is quite true that the disease, like all others, may be ill- 
developed or abortive, but it always tends to, and in its per- 
fect condition does, " discharge." Considerable error, 
however, in this respect, arises also from the fact that many 
other diseases are constantly, and have been, included under 
the term eczema which are not eczema at all, such as para- 
sitic eruptions, lichen, lichen ruber, erythema, and pityriasis 
rubra. These do not discharge, and hence the statement 
that eczema is not necessarily accompanied by discharge is 
to be ascribed in part to errors of diagnosis ; but it is impor- 
tant to remember that in typical eczema there is always 
" sero-purulent" fluid effused externally. 

Eczema attacks by preference the region of the junction 
of the skin and mucous membranes, the flexor aspects of the 
limbs or the parts where the skin is soft, the front of the 
trunk, especially in the region of folds of skin, and the scalp 
and ears. 

Eczema is, perhaps, of all diseases of the skin, the one 
most prone to assume a variety of external aspects, mainly 
because it is made up of many stages — redness, papulation, 
vesiculation, pustulation, desquamation, etc and any one of 



88 THE DETAILED DESCRIPTION 

these may be specially marked, whilst they may exist in 
varying combinations because of the different ages of the 
diseased patches in different parts. But if the disease be 
regarded from a purely clinical point of view, it will be 
found that all cases of eczema may be ranged under one of 
three chief varieties, viz. : Eczema simplex ; E. rubrum, or 
the inflammatory ; and E. pustulosum, or the pustular or 
impetiginous form. In all its forms it is usually sym- 
metrical. 

(1) Eczema simplex includes those phases which are more 
or less localized and affects one or two places at the most ; the 
diseased surface consisting of crowded vesicles seated on a 
red base, which on rupturing give place to a red discharging 
surface and subsequently a crusted patch. Eczema simplex 
is not attended by any marked general disturbance of the 
system, though perhaps by debility, and it is frequently ex- 
cited by local irritants, such as heat, cold, scratching, irri- 
tant dyes, etc. 

(2) E. mbrum, which is the inflammatory form, is at- 
tended by more or less constitutional disturbance, or by 
gouty or dyspeptic symptoms. In this form the local inflam- 
matory signs are very marked, that is to say, the parts are 
hot,, swollen, tender, itchy, excoriated, and they discharge 
and crust. This eruption often attacks the flexures of the 
joints, especially at the bend of the elbows, behind the 
knees, the axillae, and the bend of the thigh. It is fre- 
quently seen in young children about the head, and limbs, 
and loins, but it is equally common in the adult, especially 
such as are of good age. In younger people it may have 
existed off and on since infancy, especially about the flexures, 
and in subjects whose parents have been gouty. 

(3) E. impetiginodes or pustulosum is characterized 
especially by the early formation of pus, marked discharge, 
and free yellow crusting. It is mostly observed in strumous 
subjects, especially in children who are badly nourished and 



OF CUTANEOUS DISEASES. 89 

the victims of home neglect. Pustular eczema is commonly 
seen about the head of the young. 

The formation of the three above described varieties is 
based upon a consideration of the local and general pheno- 
mena of cases of eczema considered as a whole, and not upon 
the predominance of any one particular feature, and it is im- 
portant to add, as before indicated, that each of these varie- 
ties has similar inflammation stages, and these stages are 
often considered as constituting varieties of eczema ; hence 
the terms eczema erythematodes, papillosum, vesiculosum, 
icherosum, madidans, squamosum, etc. The reader will not 
fail to see that these terms do not signify true varieties, but 
merely the particular stage at which a given case or patch 
has arrived ; hence the simple, the inflammatory, or the pus- 
tular varieties of the disease each has its erythematous, 
papular, vesicular, weeping, crusting stages, and so forth. 
The term simple, as applied to the disease, indicates not only 
that the local phenomena are slightly marked and localized, 
but the general disturbance is not severe, and that the disease 
runs a mild general course. The term rubrum implies a 
severer development of both local and general phenomena, 
and a longer and more tedious course and more troublesome 
sequelae ; and the designation pustulosum, a peculiarity in the 
local secretion which is dependent upon a special pyogenic 
dyscrasia ; in other words, these three appellations deal with 
the total phenomena of particular sets of cases into which 
eczemata are clinically divisible, and that in a satisfactory 
manner. 

There are other terms applied to particular phases of 
eczema, but they are unnecessary encumbrances to the sub- 
ject ; of an eczema, for instance, crack, which is sometimes 
termed eczema jissum, or vimosum ; if it be attended by 
warty excrescences, E. verrucosum, etc. 

Local Varieties of Eczema — It is customary in systematic 
works to call attention to the peculiarities of eczema as it 

8* 



90 THE DETAILED DESCRIPTION 

attacks particular regions of the body, and local varieties 
are described in accordance with the locality attacked, and 
stress is laid upon eczema of the head, ears, genital parts, 
hands, and feet. A few words in explanation of these 
" varieties" will be useful. Now, clinically, it must be under- 
stood that the eczema in these " local" aspects is not so much 
completely limited to the affected region as that it is signally 
in them ; for eczema, though it may affect the ear or the 
head or other part only, is seldom limited to any one region, 
except in the commencement of an attack, i. e., before suffi- 
cient time has elapsed for it to spead widely ; or, in simple 
cases, excited by local irritants. As a rule, in fact, in the 
" local varieties," one particular region is prominently impli- 
cated, but others are also more or less involved, though in 
some cases in a slight degree. This fact must not be forgotten 
in reference to the following descriptions of " local varieties." 
JE. capitis occurs usually under two main sets of circum- 
stances, viz., in the young of lymphatic temperament, when 
it assumes the form of JE. rubrum or pustulosum, and in 
elderly people of gouty tendency and associated with the same 
disease about the ears, and the hands and face perhaps. 
When the child is attacked it will be found to be more or less 
debilitated from having been imperfectly or improperly fed ; 
and to be the subject of pale stools, indicative of imperfect 
liver action. The scalp and face swell greatly, ooze freely, 
and crust, while the glands in the neck are enlarged and 
painful. In the case of the adult, E. capitis is in our esti- 
mation an indicative in the majority of cases of a gouty 
tendency, in connection with more or less debility. It is 
often very itchy, and the scaliness is marked. I have no- 
ticed in elderly people that eczema of the scalp and legs is 
followed by a warty thickening of the skin, the little scat- 
tered spots or patches, varying in size and elevation from a 
split pea to a large almond and more. The spots are firm, 



OP CUTANEOUS DISEASES. 91 

coarse, and feel harsh. They need caustics, or painting with 
tar or chromic acid solution, for their removal. 

E. mammcB is often associated with scabies in the female. 
"When eczema attacks the submammary folds it is only a 
part as the role of a more general distribution of the disease, 
which likewise attacks the pubic region, the bend of the 
thigh, *. <?., the groin, the perineum, and the anal region, or, 
as it is termed, eczema genitale. This eczema of opposing 
parts takes the aspect of E. rubrum. The eruption is often 
extensive, painful, itchy, and is attended by much excoria- 
tion, swelling, and free oozing, whilst an offensive odor is 
exhaled at times. The disease runs a very chronic course, 
and greatly distresses the patient. Good observers have af- 
firmed that glycosuria is common in connection with eczema, 
and irritation of the vulva and parts around, but in our ex- 
perience, although this is often the case, the connection is not 
very frequent. "We inclined rather to the view that a gouty 
tendency is more usually present. Glycosuria is of course 
observed in connection with many forms of skin eruption, as 
psoriasis and eczema, and it is always a cause of aggrava- 
tion, but we do not believe that it can be looked upon as 
the cause in many cases of eczema genitalium. 

Eczema of the axillce is common under similar conditions, 
but in our experience is an indication of general debility, 
and especially so when it is attended by suppuration of the 
axillary glands. 

E. aurum (or of the ears) is common in elderly people of 
gouty disposition. One or both, the inside or the outside, 
or all the surface of the ears, may be affected. The ear 
often swells very considerably, and, if the disease become 
chronic, may remain greatly enlarged for some time. 

E. manuum is usually symmetrical ; it may be a part of 
general eczema when it exhibits the typical characters of 
that disease, or it exists with little eczema of other regions, 
when it frequently assumes a dry aspect, and simulates 



92 THE DETAILED DESCRIPTION 

psoriasis. It attacks the palms, the fingers, perhaps the 
wrists or the back of the hand together, and the nails may 
also be implicated. It leads to considerable cracking about, 
and subsequent pain, of the fingers. 

E. 'pedum is likewise a part of general eczema, or it may 
exist especially about and between the toes in an isolated 
manner, and we are convinced that this is common in gouty 
subjects, though they may be also debilitated. The swelling 
of the toes may be very great, the pain, the smarting, and par- 
ticularly the itching intense ; the surface, especially where the 
toes come into contact, inflamed and raw, whilst the cuticle 
becomes macerated by the fluid which collects in the inter- 
digital parts. The foot sometimes swells considerably across 
the bases of the toes on both the flexor and extensor sur- 
face. 

Before passing to the subject of treatment, we venture to 
add that all these several manifestations and varieties of 
eczema now described are greatly modified by the constitu- 
tional tendency of the individual. Eczema in a nervo-bilious 
subject will tend to be specially irritable ; in a gouty one, 
inflammatory ; and in a scrofulous one, to be speedily and 
freely pustular. 

Diagnosis. — Eczema may be readily confounded by the 
student with psoriasis, lichen planus, pityriasis rubra, erysi- 
pelas (in the case of the face) pemphigus foliaceus, dysidrosis 
(in the case of the hand), scabies, and seborrhoea. Eczema, 
in its dry scaly stage, simulates psoriasis, but it lacks the 
white, silvery, abundant scales, the bleeding corium on re- 
moval of the scales, the predilection for the elbow and knee 
regions of the latter, whilst it possesses a history of an ante- 
cedent moist stage, it attacks the flexor aspect of the limbs, 
it is very itchy, its scales are the product of dried discharge, 
in great measure, and not solely epithelial. 

Lichen planus and ruber always presents characteristic 
flat topped shining papules on some part of the surface. 



OF CUTANEOUS DISEASES. 93 

Pityriasis rubra is the only disease that rapidly involves the 
whole surface of the body, and sheds abundant scales without 
there being any discharge ; it thus lacks the essential feature 
of eczema. Acute eczema of the face, when accompanied 
by much swelling, may simulate erysipelas, but the general 
symptoms are comparatively slight, and the eczematous cha- 
racter of the eruption will certainly be detected toward the 
outside of the eruptive patches or area or beyond it ; whilst 
the peculiar shining and glossy, smarting surface of erysi- 
pelas will be absent, and the " discharge feature" of eczema 
soon be apparent, a day or so will clear the diagnosis up. 
Pemphigus foliaceus in its later stages closely simulates ec- 
zema, but the origin of the disease from distinct bullae, and 
their clear recognition up to the date of the close aggrega- 
tion of the bullae, the presence of abortive bullae, the peculiar 
flakiness of the surface, the flakes, like bits of pie crust, 
answering in shape and size to the antecedent abortive bullae, 
the peculiar sickening odor, and the general emaciation and 
weakness of the patient, and the want of dermic infiltration 
are not like the phenomena of eczema. The diagnosis of 
eczema from dysidrosis is given under the description of the 
latter. Scabies ought to be recognized when it is an excit- 
ing cause of eczema by the characteristic appearances inci- 
dental to the presence of cuniculi about the hands and the 
genital parts. Seborrhoea does not discharge, but consists 
of greasy, flat, readily removable scales. 

Eczema manuum is not unfrequently mistaken for palmar 
psoriasis, and vice versa, but in a large number of cases 
typical eczema will be found elsewhere in cases where the 
hand is the seat of eczema, whilst if it be confined to the 
head it will be found to have " weeped" at some period, and 
the scaliness that exists will not be essentially epithelial, as 
in psoriasis, but made up in great measure of inflammatory 
material. 

Treatment It is of great consequence in the treatment 



94 THE DETAILED DESCRIPTION 

of eczema whether the subject be a private and well-to-do 
patient, or a needy one attending a hospital or dispensary ; 
for the simple reason that the latter is unable to give that 
amount of rest and attention, more especially to the local 
treatment, which is so conducive to the amelioration of the 
disease. The hospital patient, of course, is mostly compelled 
to follow his usual avocation, which not only interferes with 
his using his remedies properly, but often exposes him at 
the same time to many sources of additional local irritation, 
such as the contact of dirt, acrid substances, and muscular 
exertion attendant upon the exercise of his calling. The 
hospital out-patient cannot, moreover, regulate his living as 
he ought. 

In E. simplex all causes of local irritation are to be re- 
moved, and the part protected locally by dusting it over with 
such as (48 or 49), or (14) may be applied. This should 
be followed up by (76). A very good ointment for these 
cases is the boracic acid ointment made after Lister's for- 
mula, but carefully prepared so as to be free from grit. In- 
ternally, a mild aperient, salines, if needed, for a day or 
two, to be followed by quinine and iron (109) will be bene- 
ficial, since the outbreak or its persistence is very often fa- 
vored by debility. 

E. rubrum requires more active treatment. Any gouty 
tendency must be carefully met by appropriate dietetic and 
medicinal remedies, all stimulants being at first avoided. 
The part locally is to be soothed by absorbent powders, or 
bathing with poppy water, and subsequently dressed with 
linimentum calcis, or should there be much burning (18), 
(41), or (74). Sometimes, indeed, all the remedies will fail 
until a loaded system has been relieved by aperients with 
small doses of colchicum, or excess of acid generated in the 
system be corrected, or dyspepsia remedied. In all cases of 
eczema with much pain or redness, aperients are of greatest 
value, and should be used freely. When the part affected 



OF CUTANEOUS DISEASES. 95 

n eczema rubrum is less irritable and red, (62) or (76) may 
be employed with tonics, especially arsenic, with alkalies, 
iron, or quinine (90), (107), (108). If the part become 
chronically thickened and indolent, an alterative mercurial 
course with bark will be found beneficial, at the same time 
that tar and weak mercurial ointments are applied (60), to 
be followed in the still more chronic cases by blistering, if 
need be. 

E. impetiginodes requires the internal free and continuous 
use of cod-liver oil, iron, and quinine, with suitable food, 
and locally the application at the outset of simple oil, to free 
the part from crusts, followed by the linimentum calcis, and 
then a weak white precipitate ointment, as, for instance, gr. 
iij to the ^j or (62). 

In regard to local varieties, before described, some few 
remarks may be made. In E. capitis, which is almost 
synonymous with E. infantile, the child will be found pale, 
and very likely more or less cachectic. Bad or insufficient 
food is the cause of the majority of such cases, and the reme- 
dies chiefly required are better food, cod-liver oil, arsenic, 
and steel wine ; but due attention should be given in the 
first instance to the torpid action of the liver, which is so 
often found to be indicated by pale putty -like stools. Clean- 
liness and the use locally of the remedies stated to be appro- 
priate for E. impetiginodes are to be employed ; for, as a 
matter of fact, E. infantile and E. capitis take on the char- 
acters for the most part of that variety, though occasionally 
those of E. rubrum. Should there be any difficulty in re- 
moving the crusts, the affected part may be kept soaked in 
oil until they are loosened and detached, when a weak white 
precipitate or nitrate of mercury ointment may be used with 
advantage. In the adult, E. capitis occurs in the gouty, 
and requires similar treatment to E. rubrum, locally at the 
outset, if there be much oozing or inflammation an ointment 
made by rubbing together a drachm of liquor plumbi and an 



96 THE DETAILED DESCRIPTION 

ounce or more of vaseline does good and soothes, but in 
chronic conditions nothing is better than one composed of 
five grains of the white precipitate, a like amount of nitric 
oxide of mercury finely levigated, and an ounce of fresh 
lard, applied night and morning to the scalp or the affected 
parts, 

E. mammce, if excited by scabies, disappears in the cure 
of that malady. 

E. manuum and E. pedum are examples of E. rubrum. 
If the former is often excited by flour, as in bakers, by sugar, 
as in grocers, and by soda, as in washerwomen, the sources 
of irritation must be removed. The external treatment con- 
sists, in simple cases, of tonics with some slight alkali in 
them. 

In the case of the toes being attacked, small doses of col- 
chicum with alkalies, iron, and arsenic do most good in our 
experience. Locally very marked inflammation must be 
soothed by soaking freely in linimentum calcis at night, and 
use No. 74 (without the mercurial preparation) in the day- 
time, adding to it so soon as the parts will bear stimulation 
some tar preparation ; that known as the Wright's liq. car- 
bonis detergens in the proportion of two drachms to six 
ounces of the before-quoted lotion. No. 74 is as good as 
any. In some cases of indolent disease India-rubber gloves 
worn at night are effective. In eczema of the legs, if there 
be much ©edematous infiltration, the liberal exhibition of 
diuretics in conjunction with rest, careful bandaging, and 
the use of (76) or a weak mercurial ointment, is all that is 
needed to effect a cure ; though often tonics and good feed- 
ing are very useful adjuncts. 

Elephantiasis The term Elephantiasis has been long 

used as a generic one for two distinct diseases, but these bear 
no real relation to each other. The one is Elephantiasis 
Arabum, or the elephant leg ; the other the Elephantiasis 



OP CUTANEOUS DISEASES. 97 

GroLcorum, or the true leprosy, which we shall describe now 
under separate headings, taking E. arabum first. [A third 
form, Elephantiasis telangiectodes, having peculiar features, 
will be subsequently considered.] 

Elephantiasis Arabum. — This disease is also known 
as Tropical big leg, Barbadoes leg. Elephant leg, Pachydermia, 
Bucnemia tropica, and Spargosis. It is characterized by an 
hypertrophy of the skin and subcutaneous tissue, leading to 
great deformity and enlargement of the limb, with thicken- 
ing, induration, and Assuring of the integuments, and more 
or less papillomatous or warty growth of the skin. It is 
ushered in and attended throughout its course by recurrent 
attacks of febrile disturbance of greater or less severity, and 
by lymphatic and glandular inflammation and its conse- 
quences. Though isolated cases occur all over the world, 
here and there, the malady is essentially an endemic disease 
of tropical parts. It attacks males by preference to females 
in the proportion of about five to two. The poor and ill-fed 
are much more prone to it than the well-to-do ; and agricul- 
turists and those who are exposed to the sun, in damp and 
humid regions, are more peculiarly liable to be attacked by 
it. As regards the age of individuals affected by elephant 
or tropical big leg, it may be said with pretty tolerable cer- 
tainty that the disease is rarely found in persons of less than 
fifteen years of age, whilst it occurs most commonly in those 
between the ages of fifteen and forty. The leg is the part 
generally attacked, and indeed in more than 90 per cent, of 
all cases, though the joints, the scrotum, the arms, and the 
face suffer occasionally. The average size of the normal leg at 
its biggest part is said upon good authority to be about fifteen 
inches in circumference, but the limb maybe increased to be 
as much (according to Mr. Vincent Richards) as thirty-six 
inches round. 
9 



98 THE DETAILED DESCRIPTION 

In some cases several members of the same family may- 
be attacked, which fact may be explained either by regard- 
ing the affection as hereditary, or on the score that they are 
all subjected to similar influences. The affection is usu- 
ally of very chronic production, and when the enlargement 
has once taken place, it is permanent. The swelling accom- 
panying each recurrent erysipelatoid attack remains after 
the subsidence of the fever, and so the limb gradually en- 
larges. The affection is not often fatal, but patients die from 
intercurrent diseases, or exhaustion from secondary causes. 

The relationship between the enlargement of the limb, the 
fever, and the lymphatic inflammation is, in an etiological 
point of view, not well defined. It is usually taught that the 
disease and its exacerbations are ushered in by distinct at- 
tacks of "fever" of some few days' duration, and to which 
the term u elephantoid fever" has been given by Sir Joseph 
Fayrer ; and that coincidently or immediately following as 
a consequence, redness, pain, and tension, and perhaps knot- 
tiness, are noticed over the course of the lymphatics of the 
limb, which become enlarged and otherwise diseased. But 
there are many exceptions to this sequence of events. 

A good deal of information has recently been collected 
upon this particular point, 1 and it is certain — first, that the 
disease may come on insensibly, and develop gradually, with- 
out any febrile disturbance at all, as in twenty-two out of 
636 cases collected by Mr. Richards, of Balasore, and twenty- 
six out of eighty-seven cases tabulated by Sheriff Mooden 
Khan Bahadur (Triplicane, Madras), and in some cases 
without any lymphatic inflammation ; secondly, that in a 
large number of instances, local attacks of inflammation of 
the limb or lymphatics are preceded or ushered in by febrile 
attacks lasting from two to three days ; thirdly, that the two 

1 "Endemic Skin and other Diseases of Hot Climates," by Drs. 
Farquhar and Tilbury Fox, 1876. Churchill. 



OF CUTANEOUS DISEASES. 99 

conditions may be coincident ; and, fourthly, that the febrile 
paroxysms are frequently secondary to glandular inflamma- 
tion. 

The tendency of modern writers is to regard the disease 
as essentially the result of lymphatic inflammation and ob- 
struction, the febrile attacks being due to the lymphatic mis- 
chief. As regards the cause of the lymphatic disease, two 
main theories are in favor : one which attributes it to an 
altered blood-state, induced by climatic influences, and. in 
connection with which exposure to cold and damp operates 
as a speedy excitant of lymphangitis ; the other is the pre- 
sence of filariae in or about the lymphatics. The latter ex- 
planation as the cause of common uncomplicated elephanti- 
asis, to our mind, cannot be entertained at present. The idea 
that filariae are the cause of elephantiasis has arisen thus : 
filariae have been found in the lymph and blood in cases ot 
enlargement of the scrotum, with exudation of chyle-like 
fluid (chyloderma). They have also been detected in cases 
of elephantiasis in connection with this so-called "lymph- 
scrotum ;" and it has been assumed that as filariae cause the 
lymphatic varix in the one, it must do so in the other form 
of scrotal and in leg enlargement, in which chyloderma, 
or chyluria, is absent ; but it is assumed that the two condi- 
tions — the chylous and non-chylous enlargements — are the 
same. 

But facts at present seem to indicate that filariae have not 
been found in uncomplicated elephantiasis — that is, in dis- 
ease without chylous exudation ; and secondly, that filariae 
occur only in connection with chyluria (chylous abscess, as 
shown by Dr. Bancroft especially) and its associated condi- 
tion, the escape of chyle from the skin, or chyloderma. 
Filariae, therefore, are the cause of the conditions associated 
with chyluria and chyloderma, and not of elephantiasis ; but 
the former may complicate the latter. 

It must be allowed, also, that the fact that filariae are often 



100 THE DETAILED DESCRIPTION 

found, and have existed some time, in the blood and urine 
of patients who exhibit no symptoms or signs of elephanti- 
asis, is a strong argument against their presence being the 
real cause of the latter disease. 1 The concurrence of filari- 
ous blood (filarious abscess) and elephantiasis, in the same 
subject is not surprising when it is recollected that these 
things are co-endemic and common in the regions where they 
are chiefly observed ; and what, therefore, at first sight seem 
to be cause and effect may after all be best explained — see- 
ing that there is no necessary connection between the two — 
as a concomitance. It has yet to be proved that " true lymph- 
scrotum" (varix lymphaticus), and true elephantiasis are 
identical diseases. 

In England we occasionally observe a condition answering 
in all its naked-eye characters to elephantiasis of the limb, 
in patients who have never been out of England, as sec- 
ondary to eczema; and it would seem that the disease is to 
be explained as an hypertrophy of the whole textures, the 
immediate consequence of long-continued hyperemia. But 
as we frequently notice long-continued hyperemia without 
much hypertrophy of the leg-tissues, it is but fair to assume 
that where elephantiasis does occur there must exist some 
special proclivity on the part of the tissues to take on, un- 
der favorable circumstances, a hyperplasic increase ; so that 
it can scarcely be said that the hyperemia is the true cause 
of the elephantiasis. 

Anatomy When the tissues are cut into with a knife, 

they are found to be very firm, and sometimes almost like 
gristle, both in consistency and appearance. Microscopic 
examination shows great papillary hypertrophy, varying in 
degree in different situations, with consequent heaping on of 
the epithelium and enormous overgrowth, and dense felting 
together of the corium, and especially the subcutaneous con- 

1 Dr. Manson, of Amoy, in the Chinese Customs Gazette. 



OF CUTANEOUS DISEASES. 101 

nective tissues. The bloodvessels are enlarged and gorged 
with blood. The condition of the lymphatics is very im- 
portant. The vessels are much dilated, and the "juice 
tracks" around the bloodvessels attain a great development, 
and show prominently as large tracks of adenoid tissue under 
the microscope. The neurilemma of the nerves is often 
greatly thickened. As secondary changes at an advanced 
stage of the disease the fat and muscles are found atrophied, 
and the bones may be thickened in various ways. 

Diagnosis There can be but little difficulty about the 

diagnosis of the affection, but true E. Arabnm must not be 
confounded with the hypertrophic conditions induced by 
prolonged eczema, or other irritation. It seems probable, 
too, as shown above, that true E. Araoum differs from the 
closely similar conditions induced by the escape of chyle in 
the skin (Chyloderma). Lastly, there are rare hypertrophic 
conditions, mostly congenital, accompanied by overgrowth or 
dilatation of the blood and lymph vessels, called E. tele- 
angiectodes, 1 which bear no real relation with this disease. 

In all cases it is essential that patients attacked by ele- 
phantiasis Arabum should be moved away from the endemic 
haunts of the malady, to a healthy, elevated, and bracing 
locality. This, in itself, is often of great benefit. In ad- 
dition, and as a matter of course, the general health should, 
if it need, be improved by proper medicinal and hygienic 
treatment. Much has been said of late in India in favor of 
a purely milk diet in the treatment of the disease. Of this 
we know nothing personally, but have seen much benefit 
from the free exhibition of quinine. It lessens the severity 
and frequency of the " febrile paroxysms," and so indirectly 
tends to repress the disease. But, in fact, no internal medi- 
cines can be depended upon to exert any direct and specific 

1 Hebra on Diseases of the Skin and Busey on Lymph Channels. 

1878. 

9* 



102 THE DETAILED DESCRIPTION 

influence upon the disease. During the febrile paroxysms, 
salines, with aconite and quinine, are the proper remedies, 
with opiates to relieve pain. The local treatment is very 
important, and comprises rest, frictions, inunctions, bandag- 
ing, prolonged pressure, arterial compression, and ligature of 
the main arterial or nerve trunk supplying the affected part. 
In the lesser marked cases, absolute rest, with frictions with 
mercurial or camphor or iodine liniment, and careful pro- 
longed bandaging, have been followed by favorable results. 
Should these means fail, or should the case be one of long 
standing or of great severity, it becomes a matter of con- 
sideration whether some more serious measures should not 
be adopted. If large intractable ulceration exists, the limb 
may be amputated. 

Prolonged compression of the main artery (digitally or 
otherwise) has been practised by Dufour, Vanzetti, Hill and 
Cockle, Gosselin, Bardeleben, and others, with varying suc- 
cess ; but it is worthy of trial. As regards ligature of the 
main artery there is a difference of opinion, owing to the 
tables compiled by various authors not giving properly the 
subsequent history of the case. We have before us a table 
collating thirty-seven cases in which this operation has been 
performed. In almost all there was temporary amelioration, 
in many no subsequent history is given, but where this was 
recorded there was almost always a relapse. Butcher's was 
the one really successful case, the patient being well four and 
a half years afterwards. On the w r hole, the operation is 
very unsuccessful. [Dr. Thos. G. Morton, of Philadelphia, 
in 1877, excised about two inches of the sciatic nerve in a 
case of elephantiasis at the Pennsylvania Hospital, with ap- 
parently satisfactory results. The patient subsequently con- 
tracted pneumonia, and died within a year with phthisis. 
His leg greatly diminished in bulk after the operation, and 
never regained its former size, before the operation, but his 
extended stay in bed may have aided this result, as well as 



OF CUTANEOUS DISEASES. 103 

the general wasting that occurred in all the tissues during 
his prolonged sickness.] 

Elephantiasis Grffieorum.-^-This, the true leprosy, 
consists in a profound alteration of the nutrition of the body 
as a whole, the consequence of the operation upon the system 
of special climatic influence or an hereditary tendency to 
the disease. This evinces itself by the formation of a new 
growth possessing the physical characters of granulation 
tissue. The disease develops itself chiefly in the skin, the 
mucous surfaces, and the nerve trunks ; giving rise to thick- 
ening and deformity, especially of the face, together with 
ulceration from degeneration of the leprous tissue itself, and 
to various symptoms of disordered sensibility, particularly 
ancesthesia, and to erruptive lesions in the skin, which are 
the direct result of the invasion of the nerve trunk by the 
same nerve tissue. There are two chief sets of leprosy 
cases, the one in which the deposit of new leprous material 
in the skin is marked, and the ancesthesia is only moderate 
in degree, and the other in which the nerve tissues are 
specially involved, ancestkesia and atrophous changes beino- 
very decided, whilst the deposit of leprous tissue is com- 
paratively slight, but there is no sharp line of demarcation 
between the two forms, which Ave denominated respectively 
the tubercular and the ancesthetic. Clinically, the distinc- 
tion of these two varieties is very convenient. 

The tubercular form is known in its fully developed stage 
by three sets of symptoms, (a) discoloration of the skin, of a 
light coffee hue, often mistaken for syphilitic maculation ; it 
may be preceded by slight redness, and it shows itself in a 
few spots first of all, and then in many places over the body 
and limbs ; (b) deposit of a new growth in the skin in the 
form of dull red tubercles or infiltrations ; this deposit is 
chiefly found about the face and ears, so that the eyebrows, 
cheeks, forehead, ears, nose and its alae, become dull copper- 



104 THE DETAILED DESCRIPTION 

colored, coarse, uneven, and greatly distorted from the 
thickening, the countenance presenting a fierce or leonine 
appearance ; it is also observed in the seats of discoloration ; 
and (c) anaesthesia of different parts, especially parts of the 
extremities, and particularly some or all of the fingers or 
toes at the outset, due to the deposit about the superficial 
nerve trunks, of the same new growth as that which invades 
the skin. In the anaesthetic form the deposit in the skin is 
not so marked, but anaesthesia is well developed, and crops 
of bulla? (which leave behind atrophous spots), and another 
kind of eruption, consisting of more or less circular, well- 
defined, dull red, quasi-psoriasic but ancesthetic, circular 
spots of eruption are observed. These patches often appear 
about the hands in the early stage, then in various parts of 
the body and trunk, as dull red maculations in their early 
stage, but after a time they look like patches of fading psori- 
asis circinata, or seared skin, the central part being ap- 
parently slightly depressed and paler than the outer portion, 
which is more prominent, looks thickened, and is very 
slight scaly, the whole patch, however, being anaesthetic. 
Such patches are, as the disease progresses, scattered about 
the body, more or less symmetrically. The hands often get 
distorted, and the fingers contracted, so that the hand assumes 
a claw-like aspect. The cutaneous tissue itself becomes 
lax, dark colored, dry, and fits loosely in wrinkles over the 
bones. 

Diagnosis. — It is almost impossible to confound leprosy 
with any other disease, if attention be paid to the presence 
of anaesthesia, in the eruption patches and the extremities. 

Treatment Much has been said of late about reputed 

" cures" of leprosy and " specifics" for the disease, but 
they have proved fallacious. The disease may, however, be 
greatly ameliorated by the use mainly of external remedies, 
but there is no known cure for leprosy. In dealing with 
lepers the first thing to be done is to remove them out of the 



OF CUTANEOUS DISEASES. 105 

reach of all unhealthy conditions. They should, if in them, 
be taken from localities where leprosy is endemic, and sent 
to a temperate and bracing climate. Next, they should al- 
ways be placed under favorable hygienic conditions, be pro- 
vided with a liberal supply of fresh animal and vegetable 
food, be properly clad, housed, and tended, take due exer- 
cise, and indulge in frequent proper ablution. It is necessary 
too for the leper to have his mind actively and healthily 
occupied by engaging him with proper employment. A 
general tonic treatment should be carried out by the mineral 
acids, ferruginous preparations, bitters, and especially by 
large doses of quinine, from which we have obtained very 
favorable results. A word may be added here with regard 
to the treatment by the Cashew and Gurgun oils, for which 
great results are claimed. These oils may be administered 
internally, and they are recommended to be rubbed into the 
patches and tubercles of leprosy freely and persistently. 
They certainly have the effect of removing the tubercles in 
a great measure, but only temporarily, and the diseased con- 
stitutional state is not cured. 

Elephantiasis Telangiectodes. — Virchow has de- 
scribed under this term, and Hebra and Kaposi under that of 
Lymphangiectodes, a form of congenital hypertrophy occur- 
ring principally in acephalous and other monsters, which in 
these involves frequently the whole body, but in viable indi- 
viduals only invades one or more localities. In this disease, 
primarily and chiefly, the cellular tissue is involved ; it be- 
comes so hyperplasic that " elephantoid" enlargements occur. 
Generally the whole limb is affected, but the condition may 
be quite localized. The tissues depend in great folds or rolls 
and the outgrowth contains many bloodvessels. In one case 
the growth may be chiefly lipomatous, at another vascular 
or ncevoid, at another the lymphatics, may be particularly 
abundant and enlarged, and in rare instances they may be 



106 THE DETAILED DESCRIPTION 

varicose and even burst and give exit to lymph ; but these 
cases are not common and can scarcely be discussed in this 
work. 

Epithelioma, or Epithelial Cancer, in its typical 
form, and in which it runs a rapid course with free ulcera- 
tion, gland implication, and the like, occurs in elderly per- 
sons, and attacks by preference the lower lip. It begins by 
a " crack" that gradually hardens at its base, or as a hard 
lump often where the lip has been irritated by friction with 
the pipe in habitual smokers, and the presence of this little 
lump makes the lip feel swollen and "pouty." This lump 
soon cracks in the centre from the setting in of ulceration ; 
and when this takes place the progress of the disease is often 
very rapid. The ulcer, which is now soon produced, is foul, 
and its edges are everted, indurated, and undermined. The 
glands under the jaw become enlarged and indurated, and 
then the disease makes rapid progress and carries off the 
patient. 

Treatment. — There is only one thing to be done in epithe- 
lial cancer, and that is to remove the disease in as early a 
stage as possible and as freely as circumstances will admit. 
The form of epithelial cancer termed " Rodent ulcer" will be 
described for convenience sake under that heading. Cer- 
tainly the two are phases of the same disease. 

Erythema is simply redness or hyperemia, and this 
has already been described under the head of Elementary 
Lesions. Redness of course may form a part of very many 
dissimilar diseases, all those, in fact, in which inflammation 
or active congestion occurs, but then it plays only a subsidi- 
ary role in these maladies. Reference is here particularly 
made to erythemata, which in themselves constitute the con- 
dition or disease requiring treatment. 



OF CUTANEOUS DISEASES. 1 07 

The true erythemata may be divided into two main groups : 

The first group of erythema cases includes all those in- 
stances of hyperemia which are excited by local irritants of 
Various kinds, as parasites, heat, cold, friction, scratching, 
flannel, etc., and also comprises such erythemas as are in- 
duced by the rubbing together of two folds of skin, and are 
accompanied by a muciform discharge, and to which the term 
intertrigo is applied. 

The treatment of this set of cases is simple. It consists 
in removing all local causes of irritation, and simply sooth- 
ing the part by such remedies as (13), (14), (36), (74), 
followed by (10), (39), or (72). In intertrigo (48) and 
(49) are specially useful ; and in some cases it is necessary 
to give children tonics, particularly steel wine and cod-liver 
oil. In the intertrigo of old and fat people diuretics and 
alkalies, followed by tonics and dressing the parts continu- 
ously with (13) or (76), constitute a good mode of treatment. 

The second group of cases includes the erythemata con- 
nected with generally slight, very rarely decided, systemic 
disturbance, and often with a rheumatic diathesis. There 
is rather more swelling than in the slighter forms, and a de- 
cided amount of effusion, so that whilst the erythema may 
spread in circles or in general well-defined areas, the disease 
is attended by papulation or the formation of irregular, and 
sometimes large nodular swellings ; hence the terms E. cir- 
cinatum, E. marginatum, E. papulatum, E. tuberculatum, 
and E. nodosum, etc. 

The particular aspect of the erythema in a given case 
varies considerably, according to the amount and particular 
extent of the effusion and the redness, and in some cases the 
varieties portray each their characters ascribed to them ; but 
in a large number of cases, on the other hand, several or even 
all the aspects of the above-named varieties may coexist in 
the same patient. Hebra has indeed discarded the use of 
the terms indicative of these varieties, and employs that of 



108 THE DETAILED DESCRIPTION 

E. multiforme as an inclusive one, on the ground that all 
the so-called varieties "are merely forms of the same disease 
in different stages, the appearance varying according as the 
affection is undergoing development or is in a later period of 
its course, or subsiding." This is not quite a correct repre- 
sentation of clinical facts. The truth is as above stated. A 
few words may be added to complete the description of the 
different phases of the erythemata. These eruptions are 
symmetrical and attack by preference the backs of the hands 
and fingers, the forearms, the legs, and the feet on their dor- 
sal aspects, and the face and sides of the neck. The trunk 
generally escapes. When the eruption is made up of rings 
it is termed E. circinatum. The rings vary in size from a 
sixpenny piece to that of half a crown or so. This phase 
often attacks the neck and forehead, though it is mixed with 
other forms of erythema. If several circles coalesce, so that 
serpentine lines or bands are produced by the blending of the 
separate segments of circles, a gyrate aspect is presented, and 
the eruption is termed E. gyratum. Rarely a series of 
concentric lines of erythema of different lines are present, 
and this is termed E. iris. The most common form is that 
of Erythema papulatum and E. tuberculatum combined. 
The rash, which predominates, is made up of soft, red, 
slightly raised, and infiltrated papules and tubercles, varying 
in size from that of sixpence to a shilling, dotted over a gene- 
ral red blush, which soon assumes a bluish color, and fades 
away like a bruise. A little itching, or tingling, is present. 
Each spot runs its course in a few days, but the disease is pro- 
longed by successive crops for two or three weeks, perhaps. 
Sometimes the tissues are much swollen ; they may be even 
livid from the occurrence of decided oedema, and more or 
less extravasation of blood, or escape of its coloring matter, 
into the parts, which may look just as though they were in 
a state of impending gangrene ; hence the terms E. ozde- 



OF CUTANEOUS DISEASES. 109 

matosum and E. hcemorrhagicum. These may concur with 
E. circinatum and marginatum of the neck and face. 

The diagnosis is easy. The symmetrical distribution of 
the rash, its seat at the back of the hand and forearm, the 
absence of itching of marked amount, the simple hyperasmic 
character and bluish tint of the rash, and its acute occur- 
rence with insignificant constitutional disturbance, are very 
significant of the nature of the eruption. 

E. nodosum generally occurs as a distinct phase of ery- 
thema, but not always ; it may be a part only of an E. mul- 
tiforme. In this variety there is often decided malaise, and 
perhaps pyrexia, with pains in the limbs, followed by the 
eruption, which is mostly confined to the lower extremities, 
and consists of round, but generally oval, roseolous-looking 
spots, varying in area from the size of a sixpence up to two or 
three inches long by one or more wide, having their long 
axis parallel to that of the leg, and which soon become ele- 
vated and tumid, tender, quasi -boggy in feel, and change 
color to that of a bluish tint, especially at their circumfer- 
ence. They fade away in color like bruises. The forearms 
may be attacked, and this lasts a week or ten days, but the 
existence of the disease is prolonged by successive crops of 
these nodular, hypersemic elevations. It is a symmetrical 
eruption, more frequent in females than males, and mostly 
in adolescents. It is often a painful disease, and the indi- 
vidual places are always very tender. The separate spots are 
thought to arise from embolisms in the small vessels. 

The treatment of the members of this second group in the 
slighter forms consists in giving mild, aperient salines, fol- 
lowed by quinine, whilst locally some simple astringent 
wash, such as (74) or (19), may be applied. In the severer 
cases it may be necessary to relieve a loaded state of 
system by (95) or (96), before giving quinine, and locally 
to use similar measures as in the less severe forms, or apply 
powders, such as (48) or (49). In erythema nodosum rest 
10 



110 THE DETAILED DESCRIPTION 

in the recumbent position is of prime importance, especially 
where the legs are painful. 

Favus, see Tinea favosa. 

Fibroma, or Molluscum Fibrosum, is character- 
ized by the occurrence of projections on the surface of the 
skin of outgrowths from the connective tissue of the deeper 
layers of the cutis. As the little tumors go on growing, they 
become pedunculated. A single tumor may be met with, 
and then it may attain a great size, or the whole body may 
be covered with comparatively little ones. They are met 
with in both sexes and in all countries, but the subjects of 
them are persons who exhibit a certain degree of imperfect 
development generally. The connective tissue of which 
they are composed varies in density of arrangement and in 
the proportion of cells intermingled with the fibres. The 
tumors are painless as a rule, but in our experience show 
sometimes a disposition to ulcerate or throw off exuberant 
ulcerations. Fibromata are not common, and when met 
with must be distinguished from warts, molluscum sebaceum, 
and fatty tumors. 

Treatment. — If it be important that the tumors should be 
got rid of, they may be removed by the ligature or the 
knife. They cannot be enucleated. 

Filaria Loa, and Medinensis, see Guinea-worm dis- 
ease. 

Fish-Skin Disease, see Ichthyosis. 

Follicular Hyperemia is a common accompaniment 
of many diseases, and particularly of those attended by pru- 
ritus, for in these it is readily excited by scratching, as in 
scabies, eczema, and phthiriasis. It gives rise to red papules, 



OF CUTANEOUS DISEASES. Ill 

wh«ch are seen to be seated at the hair follicles in part, and 
partly to be hyperaemic papillae. This condition is erro- 
neously styled lichen. Hyperemia of the follicles demands 
soothing remedies. 

There is, further, a condition of follicular hyperemia met 
with in adults, though but rarely. In this eruption the surface 
is uniformly dotted over with red points, every follicle being 
affected, but the papules are not very prominent, and have 
no central plug. They are almost completely removable by 
pressure. The skin of the trunk, and arms, and thighs are 
usually particularly aifected. The disease is chronic, itchy, 
very obstinate, and occurs in debilitated persons who have 
been a good deal worried and subjected to anxiety. The 
disease seems due to vaso-motor disturbances of the fol- 
licles, and more nearly allied to lichen ruber perhaps than 
any other disease. 

Fungi For the names of the several fungi causing 

parasitic diseases, see Tinea. 

Furunculus It is scarcely necessary that " boils" 

should be discussed in any considerable detail in this place. 
They are usually described as rounded, painful, circum- 
scribed inflammations of the skin, involving the connective 
tissue, and therefore more or less deeply seated, with hard, 
indurated, and inflamed bases. Slow suppuration goes on, 
and the central portion sloughs out, and constitutes what is 
called the " core." In reality the anatomical seat of boils, 
in the majority of cases, is a hair follicle or the attached 
sebaceous gland, with more or less participation of the cel- 
lular tissue around. In some cases the follicular origin of 
boils cannot be made out, hence the division into follicular 
and cellular tissue boils. It is open to question whether the 
u core" be always an " exudation," or a gland which has 
died in consequence of the inflammation. When a boil 



112 THE DETAILED DESCRIPTION 

forms, pain is first felt, and then a lump accompanied by 
tension and redness : this enlarges and suppurates. In "cel- 
lular tissue boils" gangrene may occur. These are found 
mostly on the scalp, neck, limbs, and especially the thighs 
of marasmic adults, and often children. Boils occur in those 
whose vitality is depressed by defective or depraved living, 
mal-hygiene, or exposure : also in those whose blood current 
is charged with nitrogenous waste products, and in diabetic 
patients. An exclusive meat diet, stale or unsound meat, 
over-fatigue and exercise are other excitants. Local irri- 
tants excite their formation, and they may accompany dis- 
ease in which scratching is freely practised, as in scabies, 
prurigo, eczema, phthiriasis, etc. Boils may be epidemic, 
and then occur, oftentimes, when erysipelas is rife. 

Treatment The formulse useful for boils are specially 

(95), (96), (108), and the mineral acids, internally, and 
(35), (79), and glycerine of belladonna externally. Patients 
with boils should have a carefully regulated diet, and obtain 
fresh air by change to the seaside or of occupation. Fresh 
yeast taken in tablespoonful doses three times a day is often 
very efficacious. In very debilitated persons the free exhi- 
bition of red wine or porter may effect the dispersion of the 
furunculi. Some practitioners find great benefit from the 
use of carbolic acid, or acid nitrate of mercury, to the boils 
to absorb them. 

Grocers' Itch is similar to Bakers' itch, except that it 
is caused by the irritant action of sugar. 

Gutta Rosacea, see Acne rosacea. 

Guinea-worm Disease. — This is very common in 
tropical climates. Usually what happens is this : the worm 
(Filaria medinensis), when quite small, bores its way into 
the skin, generally of one of the lower extremities, quite un- 



OF CUTANEOUS DISEASES. 113 

noticed by the patient. It nestles in the connective tissue 
for several months, when it has attained a length of perhaps 
ten or twenty inches or more, and the size and aspect of a 
piece of flattened whip-cord, of moderate thickness. It now 
sets up more or less irritation, and at one point an abscess 
threatens to form, and generally a bleb forms, which bursts 
and leaves a livid looking surface the size of a half crown, 
in the centre of which an aperture appears, through which 
the worm emerges, sometimes wriggling about in lively fash- 
ion. The parts around are brawny and painful, and the 
patient is crippled for the time. If about an inch of the 
worm be gently pulled out each morning, and wound round 
a little piece of cardboard or a quill, the parasite can be com- 
pletely removed in a few days, and the wound speedily heals 
afterwards. We have seen a worm twenty-three inches in 
length protrude one day an inch or two, and come away in a 
poultice applied the next night, in a patient to whom assa- 
foetida had been liberally given for several days previously. 

[On the west coast of Africa, at Congo and in the Gaboon 
region particularly, natives, and even white foreigners, are 
subject to the invasion of a small entozoa, called Fiiaria loa 
by Guyot, and Dracunculus loa by Cobbold, which most 
frequently makes its appearance under the conjunctiva, its 
advent causing inflammation and severe pain. It occasion- 
ally appears under the skin of the fingers and other parts of 
the body, but its favorite seat is the eye. For a fuller report 
see " The account of a Worm removed by a native Woman 
from beneath the Conjunctiva of the Eyeball of a Negress 
at Gaboon, West Africa, with a brief history of the para- 
site, and Prof. Leidy's description of the specimen, by 
Thomas G. Morton, Surgeon to Penna. Hospital," — Ameri- 
can Journal of Medical Sciences, vol. lxxiii. p. 113.] 

Herpes is a disease which is characterized, so far as its 
eruption is concerned, by the development of one or more 

10* 



114 THE DETAILED DESCRIPTION 

groups of little bullae, or large vesicles, upon an inflamed and 
somewhat raised base. This eruption in typical cases runs 
a short and acute course of about ten days. It is attended 
generally by slight pyrexia, and locally by heat, smarting, 
and a sense of tenseness in the affected part. The individual 
vesicles are chambered, and they are grouped closely to- 
gether, but do not unite. They also do not burst as the 
rule, but their contents, at first transparent, become cloudy, 
and then dry up, giving place to light crusts, that fall off 
after a few days, leaving behind only slight reddish stains. 

Herpes occurs under a variety of different conditions. It 
may exist as an independent disease, or develop in the course 
of other maladies, in which case it is said to be symptomatic. 
The latter aspect of the disease is exhibited by the herpetic 
patches that appear on the lip or face in connection with 
catarrh, pneumonia, and at the time of impending convales- 
cence in fevers, when it may also show itself on the inside 
of the mouth and on the mucous surface of the throat. 

In its simpler form, that is, when it occurs as an inde- 
pendent and the sole disorder, the eruption may be more or 
less general and symmetrical or localized. 

It attacks, in preference, the lips, the face, and the prepuce, 
and the varieties termed H. facialis, II. labialis H. prepu- 
tialis are accordingly made. But other varieties are recog- 
nized according to the appearance of the eruption. If it 
assume the ringed form it is termed herpes circinatus, an 
unnecessary designation. If it assume the form of a series 
of rings of vesicles, it is termed H. iris, and this is an im- 
portant phase. It is apt also to attack different parts of the 
body, on one side only, and then it is made up of a series of 
groups of vesicles arranged in a band-like form, and this 
aspect receives the name of H. zoster or Shingles. 

General Herpes is rare, but it may occur as an acute 
febrile condition, or come on more slowly, when it is chronic. 



OP CUTANEOUS DISEASES. 115 

The herpetic patches are disposed symmetrically, especially 
over the back and sides of the trunk, and seem to follow the 
lines of distribution of the trunk of the cutaneous nerves. 
The acute form may last two or ,three weeks, or lapse into 
a chronic condition, in which solitary isolated vesiculations 
occur together with herpetic patches, the disease getting 
worse and better by fits and starts, and being attended by 
considerable irritation and disturbance of the general health. 

Herpes Facialis and Labialis need not be described 
further. 

Herpes Preputialis or Progenitalis attacks all 
parts of the penis, but especially the prepuce, in the male, 
and the vulva of the female. The herpetic patches in the 
skin of the penis run the usual course of herpes, but do not, 
when seated on the mucous membrane, present their vesicu- 
lar aspect perfectly, and minute ulcerations soon take the 
place of vesicles ; but there is an entire absence of any indu- 
ration, and they speedily assume a healing aspect, and, 
indeed, heal quickly as the rule. It is excited chiefly by 
cold, by excess of acid in the urine in rheumatic subjects, by 
any special excitement of the genital organs, and is often 
periodic in its recurrence. "We have seen it associated with 
herpes iris, and herpes facialis in the same subject. 

Herpes Iris is a well-marked, distinct, and very definite 
disease, which was most fully and accurately described by 
Willan and Bateman ; but of late it has become the fashion 
to rename it hydroa, especially in France, an error which is 
due to the fact that the English description of the disease 
has been overlooked. It is quite distinct from true hydroa. 

Herpes iris attacks, by preference, the back of the hand 
and fingers. At first a circular spot, of somewhat dull red 
or purplish hue appears and vesiculates in the centre ; but 



116 THE DETAILED DESCRIPTION 

the condition soon alters to one in which there is a ring of 
ill-developed vesicles at the circumference surrounding the 
central vesicle ; the cuticle being more or less elevated ac- 
cording to the degree of effusion. Sometimes the central 
spot of the patch is slightly hemorrhagic. It is generally 
darker than the circumferential spots. The spots vary in 
size from that of a three-penny piece to a shilling or a little 
more. There may be one or a dozen or more in varying 
degrees of development, and they occur in successive crops. 
The disease is not painful, but somewhat itchy. It may be 
attended with rheumatic pain ; it may spread to the forearm. 
We have seen it associated with well-marked herpes circi- 
natus (non-parasitic) of the calf and trunk ; with herpes pre- 
putialis, and also attacking the lower extremities symmetri- 
cally in great severity. 

Herpes Zoster or Shingles is unilateral herpes, made 
up of several patches of eruption distributed in band-like 
course along the superficial nerves. It occurs in persons of 
all ages. When it attacks the trunk the eruption runs round 
the side ; when a limb, the band-like eruption runs from 
above downwards. Herpes zoster is preceded, mostly, by 
severe neuralgic pain along the course of the superficial 
nerves; and if the chest be the seat of this pain, it may ap- 
pear as though a sharp attack of pleurisy were impending, 
but very soon the herpetic patches begin to develop, and the 
pain abates, at once, as the rule. The patches of herpes do 
not all appear at the same time, but one after another for a 
few days, when the eruption reaches its climax. Some of 
them may be ill-developed. The vesicles soon become tur- 
bid, and gradually dry up into darkish crusts, that fall after 
awhile, and leave decided pits of dull-red hue. The attack 
of shingles lasts from two to three weeks. It may leave 
behind it severe neuralgic pain and considerable weakness in 
elderly people. If it attack the region of the face the eye- 



OP CUTANEOUS DISEASES. 11? 

sight may be more or less damaged or destroyed on account 
of the implication of the nerves. The disease is due to an 
inflammatory condition of the nerves that go to the seat of 
eruption, or probably the posterior spinal ganglia connected 
therewith. 

Diagnosis It is scarcely necessary to say that the fea- 
tures of herpes are so clear and easily recognizable that it 
cannot well be confounded with any other disease, except, 
perhaps, in the case of herpes preputialis, which may simu- 
late chancre ; but the acute, simple character of the herpetic 
eruption, made up of two or three little sores without indu- 
ration, and speedily healing, are distinctive. 

Treatment As herpes is a disease that runs, as the rule, 

a short and definite course, all that is needed is to prevent 
the rash from being irritated, and to aid the healing by the 
use of simple, soothing, and astringent applications, such as 
simple zinc ointment and the like, and exhibiting, inter- 
nally, salines at the outset if these are indicated, followed by 
quinine if need be. It is necessary in herpes zoster to pro- 
tect the eruption from rubbing and irritation by dusting it 
with (48), (49), or covering the part with cotton-wool. 
Sometimes considerable pain and discomfort are left by the 
eruption, and relief may then be given by morphia ointment, 
opiate poultices, subcutaneous injection of morphia, with or 
without quinine internally in large doses. In elderly people 
the general strength must be maintained by liberal food, and 
even wine in some cases. 

Herpes Gestationis, see Hydroa. 

Hydroa is a term much misused. It has of late been 
unhappily applied, particularly by English and French wri- 
ters to Herpes iris, and the bullous eruptions (?) produced 
by iodide of potassium, but these are perfectly distinct affec- 
tions. The name hydroa was given by Bazin originally to a 
disease which stands midway between herpes and pemphigus, 



118 THE DETAILED DESCRIPTION 

and the main features of which were an eruption of isolated 
vesicles, occurring in arthritic people, and attacking the cuta- 
neous and mucous surfaces. The disease lasts, in moderately- 
severe cases, two to four weeks or more, and is apt to recur 
in paroxysmal attacks. It may, however, become chronic. 
In some cases there are vesicles (H. vesiculeux) scattered 
over the backs of the hands, the shoulders, wrists, or about 
the knees, and rarely also the mouth, these being developed 
out of red papules. In other cases the vesicles present an 
umbilication in the centre (II. vacciniforme). In other 
cases Bazin holds that the eruption is made up of small bullae 
of different sizes, but none exceeding that of a split pea, the 
bullae often being grouped together. Now there can be no 
doubt that such a disease as is indicated by Bazin, under the 
term hydroa, exists as a distinct clinical condition, though 
very hazy notions are held in regard to it, and, as we be- 
lieve, no satisfactory or complete description of the disease in 
its several aspects has yet been given. We are, here, only 
able to indicate in a general summary the features of the 
several varieties of hydroa which we recognize : — 

In the first place there are definite symptoms of ill -health 
of a neurotic character in hydroa, or perhaps it would be 
more correct to say that in cases of hydroa it can be ascer- 
tained that patients have been subjected to a variety of in- 
fluences calculated to excite disorder of the nervous system, 
or to cause shock to the skin through that system. Of these 
we may name exposure to the cold for long periods, in in- 
clement seasons or in occupation, too rapid growth of body, 
depression from overwork of body and mind, defective living, 
great worry, and the like, any of which may be the exciting 
cause of hydroa in marked cases. 

As regards the eruption, it varies greatly in severity, but 
it is symmetrical and mostly pruritic, but this varies vastly 
in degree. It is essentially vesicular, and the vesicles are 
isolated as the rule. They develop, generally, out of little itch- 



OF CUTANEOUS DISEASES. 119 

ing papules which can be felt in the skin, and which are often 
scratched before the vesicle can form. They leave behind, 
frequently, little, red, pitted spots, surrounded by a slightly 
raised, infiltrated edge, which puckers in towards the centre. 
In marked cases the pruritis which antecedes the outbreak 
of the eruption is severe, and is relieved by the development 
of the latter. There are other cases in which small bullae 
form, and this may be associated with much pruritis. There 
are other cases in which solitary vesicles are mixed up with 
quasi herpetic patches (grouping of vesicles), in others large 
bullae may occur, and in others the herpetiform rash may 
suppurate, so that it simulates impetigo. There is a ten- 
dency in hydroa to assume the features of herpes on the one 
and pemphigus on the other hand. The rash attacks by pre- 
ference the face, shoulders, the extensor aspect of the limbs, 
and the genital regions. 

Three varieties may be conveniently made, not according 
to the aspect of the eruption only, but also as regards the 
severity of the attendant itching, and the general course of 
the disease : these are Hydroa simplex, H. herpetiformis, 
and H. bullosa vel pruriginosa. 

Hydroa simplex may be conveniently applied to the 
cases in which the eruption is essentially vesicular, and in 
which the vesicles are quite distinct from one another ; com- 
paratively few in number, limited in extent to the face or 
the shoulders, or the arms, perhaps ; without any tendency 
to grouping of the spots ; in which the course is a mild one, 
and the pruritis is slight, the general health being fairly 
good. We frequently in England observe such cases attack- 
ing the face, or the face and shoulders together. These are 
regarded as acne, but are perfectly distinct from that disease. 

Hydroa herpetiformis — In another set of cases the 
disease is more severe in all particulars, more pruritic, and 



120 THE DETAILED DESCRIPTION 

the eruption tends in part to assume an herpetic aspect, and 
indeed may be regarded as herpetiform in a great measure. 
It is more or less general. The aspect of H. simplex so far 
as regards the vesicular rash, may be also present. This 
form may be termed H. herpetiformis. We take it that 
Hebra's impetigo herpetiformis is a severe aspect of this form 
of hydroa. H. herpetiformis, as we have just depicted it, 
is, in our experience, not very rare about the genital parts. 
The disease may run an acute, but mostly has a chronic course. 

Hydroa bullosa or Pruriginosa In a third set of 

cases the rash is bullous, but the bulloe are small ; the erup- 
tion is widely scattered about the body and symmetrical. 
There is severe pruritis before the successive outbreaks of 
the fresh bullse, and also after their appearance, so that the 
patient scratches a good deal. The bullae dry away into 
little bouton-\\ke spots the size of a good sized split pea, with 
a slightly-raised, soft and red edge, and depressed centre, oc- 
cupied by a little blood crust, and towards which the cir- 
cumference puckers. This variety of disease is very chronic ; 
it is prolonged by successive increments of eruption, and the 
features of the rash of the simple or herpetic varieties may 
be intermingled with its own. This variety is probably the 
same thing as the pemphigus pruriginosus of old writers, and 
it answers to the Herpes gestationis, so well and correctly 
described by Bulkeley and others. 

Diagnosis — Hydroa requires to be distinguished from 
varicella, scabies, erythema multiforme, pemphigus in anoma- 
lous forms, and acne cachecticorum. The first is an acute 
febrile disease, the second is known by the presence of 
cuniculi ; the third is erythematous, and not vesicular ; the 
fourth is not a pruritic disease, and has characteristic bullae, 
and the last is an indolent, painless acneiform rash, devel- 
oped without any sign of vesicles or bullae, and devoid entirely 
of itching. 



OF CUTANEOUS DISEASES. 121 

Treatment This is a matter of the greatest difficulty. 

Diuretics are valuable in all acute cases in which there is 
much hyperemia associated with the rash, or the eruption is 
herpetiform in aspect. Stomach derangement, accompanied 
by a white flabby tongue and torpid bowels, inducing headache 
and " white" urates, and more or less debility, must be reme- 
died by alteratives and cholagogues before any more definite 
treatment appropriate to the hydroa, is adopted. All causes 
of depression of the nervous powers must be carefully in- 
quired into, and removed, as well as all the causes of shock 
to the skin. The diet must be good but unstimulating, and 
the general tone of health promoted by change of scene and 
air if need be, and by rest of jaded bodies and minds. The 
most efficient remedies for severe and chronic cases, in our 
hands, have been found to be cod-liver oil, with iron and 
belladonna. We much prefer cod-liver oil to arsenic in this 
as in most other cutaneous troubles, as a nerve tonic. Seda- 
tives internally and anti-pruritic remedies externally, do not 
often appear to produce any decidedly beneficial results. 
But alkaline and bran baths, with simple, soothing lotions 
are useful as topical remedies. We hope shortly to take an 
early opportunity of elsewhere recording more fully our ex- 
perience of hydroa. 

Hydroadenitis is an inflammation of the sweat glands, 
or rather the connective tissue about them. This condition 
commences by the appearance of small lumpy swellings like 
blind boils, but which do not suppurate, though they remain 
some time painful, tender, enlarged, and of a dull red color, 
like huge acne indurata spots, only that they possess no cen- 
tral pustular point or follicular orifice. 

Treatment — This consists in allaying the local inflamma- 
tion by ordinary measures, such as hot-water bathing and the 
free use of a calamine lotion, and subsequently painting with 
collodion, or stimulating the places when indolent with the 
11 



122 THE DETAILED DESCRIPTION 

application of the acid nitrate of mercury ; or, should this 
not succeed, subcutaneous puncture may be employed. In 
some cases which occur in strumous subjects, the disease is 
greatly influenced for the better by a course of cod-liver oil. 

Hyperidrosis signifies excessive sweating. This oc- 
curs under a variety of conditions. 

It is observed, in the first place, as part of a general affec- 
tion during the course of a number of febrile conditions, es- 
pecially when convalescence is impending, in which case it 
is said to be " critical." In ague it marks the "sweating" 
stage. It is common in connection with " hectic" of phthisis, 
and other disorders. It is a marked feature in acute rheu- 
matism. Usually in these cases the sweat escapes free upon 
the surface, but it may collect beneath the cuticle, and then 
gives rise to sudamina. It is not a condition requiring spe- 
cial treatment. 

Hyperidrosis is observed also as one of the results of dis- 
turbance of the nervous system, though this may not be asso- 
ciated with any recognizable organic change. Under these 
circumstances it is often unilateral, affecting one side of the 
body or face, and is only a symptom of some other more im- 
portant disorder. 

But there are other cases which cannot be said to be recog- 
nizably connected with any general disorder, but are appa- 
rently of local origin. The glands of skin of the hands and 
feet of the locality adjoining the scrotum. and contiguous 
part of the thigh, the axilla, seems to pour out an excessive 
amount of sweat, which is often offensive, and acts as an 
irritant, producing redness and swelling and even eczema, 
and very freqently maceration of the epidermis, which be- 
comes white, and peels off freely, leaving a congestive and 
perhaps discharging surface below. The fluid sweat may be 
absorbed by boots and socks, giving rise to great unpleasant- 
ness. These local hyperidroses are associated with languid, 



OP CUTANEOUS DISEASES. 123 

cutaneous circulation, and a strumous or lymphatic diathesis. 
The feet in flat-footed domestics are frequently affected. 
The disease is quite distinct from dysidrosis. 

Treatment In the class of local cases mentioned imme- 
diately above, a general tonic plan of treatment must be 
adopted, with the utmost cleanliness, and some such local 
application as belladonna or alum. The alum should be 
used in a pediluvium at night, about two ounces being used 
each time. Should the sweat have macerated the cuticle 
between the toes and excited an eczema, the parts must be 
constantly bathed, some absorbent powder used, as (48), 
(49), and then such as (10), (12), (14), (17), etc. 

Ichthyosis or Fish-Skin Disease is a morbid alter- 
ation of the structure and function of the skin, and is char- 
acterized in its slighter forms by a dirty, dry, harsh, ill-nour- 
ished, non-perspiratory, wrinkled condition of skin, which 
is covered to a varying extent by semi-detached, thin, cutic- 
ular scales ; and in its more developed forms by papillary 
hypertrophy and excessive epidermic formation, matted to- 
gether into dirty or blackened masses, looking as if mud 
had been caked on the parts, generally intermingled with 
abnormal sebum from the disordered sebaceous glands. In 
both forms the natural furrows of the skin are much exas;- 
gerated, and in the more developed cases they appear as a 
regularly arranged system of fissures and cracks. 

Between the slightest and extremest forms of development 
there are a great number of degrees of severity of the dis- 
ease, and, as they present great variation in aspect, a mul- 
titude of names have been applied, indicative of the likeness 
simulated to the skins of the shark, the snake, the rhinoceros, 
the porcupine, and crustaceans, etc. 

The slightest form of the disease, which has long been 
known in England as xeroderma, is characterized, as be- 
fore mentioned, by a dry, harsh, ill-nourished condition of 



124 THE DETAILED DESCRIPTION 

skin. The latter is thinned, dirty-looking, prominently fur- 
rowed, and covered with a slight amount of cuticular scales, 
detached at the edges and attached in the centre, presenting 
in different places, according to their size and quantity, 
various appearances. It is important to note that Hebra 
applies the term xeroderma to a totally different affection 
{see Atrophy of the Skin). 

When the xerodermatous condition is very well marked, 
and a parchment or mother-of-pearl aspect is presented, the 
disease is called Ichthyosis nacree or nitida. When, further, 
the epithelium is very abundant, the papillae are enlarged, 
the discoloration more manifest, and the whole affection 
more exaggerated, it is called /. squamosa, simplex, or vul- 
garis. 

In more extreme cases still, the epidermis may form hard, 
brittle shields, looking like dried mud, regularly fissured in 
correspondence with the natural farrows, or be raised up 
into prominent horns. To these extreme conditions the 
names /. cornea, I. hystrix, and /. hystricimus are applied. 

The appearances presented are not necessarily the same 
in all regions of the body of the same patient, or on the 
bodies of the several members of the same family affected, 
but different aspects or stages may be marked in the different 
parts ; thus xeroderma may be developed in one individual 
and ichthyosis in another. 

Usually the whole surface of the body is more or less in- 
volved, but the face generally escapes, in a great measure, 
and so do the bends of the joints, the genitals, the palms, 
and soles. The fronts of the knees are especially implicated 
in the ordinary ichthyosis. But whilst the disease may be 
diffused uniformly, it may occur, rarely, in patches or in lines 
which occasionally have some correspondence with the dis- 
tribution of the nerves. There are two features about the 
disease which should be mentioned. First, its heredity is 
often very strongly marked, and secondly it is congenital. 



OP CUTANEOUS DISEASES. 125 

As Hebra truly says, however, it is not congenital in one 
sense, i. e., present at the time of birth, though it is so in 
the sense that " the conditions necessary to the later devel- 
opment of the disease are present as an original morbid dis- 
position of the skin." Ichthyosis develops in children when 
they are somewhere about the age of two years, or a little 
before, and after going through several stages it may stop at 
one of them, and remain throughout life without further 
alteration. It should be stated, however, that there is a very 
rare and truly congenital xeroclermatous-looking condition 
occurring in children who rarely survive their birth long, 
which is really a seborrhcea. 

Pathology This consists in an alteration of the structure 

and of the functions of the skin, especially with regard to 
the sebaceous glands, and according to the variety of case 
one or more of the following conditions are in especial promi- 
nence. There is a papillary overgrowth with heaping up of 
cuticular cells, which are mixed with altered concreted 
sebum and accumulated dirt. There may also be excessive 
pigmentation. The corium is thickened, but the subcuta- 
neous fat lessened. The sebaceous glands are generally 
much disturbed in function and often atrophied, and the 
sweat glands less frequently so. The skin is always dry from 
want of perspiration in ichthyosis. Chemical analyses show 
that the inorganic salts in the skin are increased in quantity, 
especially the salts of lime, oxide of iron, and silicic acid. 

The diagnosis is not usually difficult. When occurring, 
as it rarely does, in a localized form, it might be mistaken 
for seborrhcea, but the history, the absence of papillary 
hypertrophy, and its curability will readily distinguish the 
latter. Some remarkable forms of seborrhcea simulating 
ichthyosis have been met with, and the condition is known 
as " spurious ichthyosis." The milder form, xeroderma, 
might more easily be confounded with other harsh, ill-nour- 

11* 



126 THE DETAILED DESCRIPTION 

ished conditions of the skin in the young ; but the history 
will usually distinguish it. 

Treatment — Ichthyotic conditions of the skin are incura- 
ble, though much amelioration may be given. Internally, 
in all forms, general tonics and cod-liver oil should be given. 
Externally, for the xerodermatous conditions, the skin should 
be kept greased by any preparation most agreeable to the 
patient, such as elder-flower ointment, olive oil, vaselin, etc. 
This should be specially insisted on in the winter, when the 
discomfort attending these conditions of skin are always ex- 
aggerated. In the most marked conditions the crusts must 
first be removed by prolonged use of alkaline baths, mild 
soap, glycerine, tar, and such like remedies, but these must 
not be allowed to irritate, and when once the skin is got 
clean, it should be kept so by constant bathing and greasy 
inunctions ; for if these applications be left off, the disease 
tends to return. 

Impetigo is a pustular eczema. See Eczema. There 
is a specially contagious variety, which we will describe un- 
der its title of Impetigo contagiosa. 

Impetigo Herpetiformis, see Hydroa. 

Impetigo Contagiosa In the year 1864, Dr. Til- 
bury Fox described, in the British Medical Journal, this 
special form of cutaneous disease, which had up to that time 
been confounded with ordinary impetigo, and classed with 
other eruptions by writers under the indefinite term " por- 
rigo." In the Journal of Cutaneous Medicine (1868) he 
re-discussed the subject, and added further illustrative cases. 
The disease was soon recognized by Clifford Allbutt, Mc- 
Call Anderson, and others in England ; by R. W. Taylor 
(1871), Piffard, Bulkley, and others in America; and by 
Kaposi (1871) in Vienna. 



OF CUTANEOUS DISEASES. 127 

The disease may be epidemic, but is mostly sporadic, and 
it mostly attacks the children of the lower orders ; but it 
occasionally occurs in those of a better position, though the 
cleanliness exercised with the latter, limits materially the 
spread of the disease. A characteristic feature is that the 
subjects of it are often healthy, thus pointing to a difference 
between it and eczema. The eruption is generally preceded 
for a day or two by malaise, which may be slight, and even 
unnoticed, or quite severe, and its evolution is now and then 
accompanied by a certain degree of pyrexia and constitu- 
tional disturbance. The eruption consists at first of coarse, 
isolated, and discrete vesicles 1 or small bulla? — " little watery 
heads" — which very rapidly become pustular and opaque, 
flattened, and, it may be, umbilicated. In the slighter forms 
there is no inflammatory areola, but in the severer forms 
there is a zone of redness around the vesico-pustules. In 
five or six days the spots reach the size of a large pea, or a 
three, four, or six-penny piece, and, if unruptured, in some 
cases a larger size. The vesico-pustules then dry into flat, 
yellow crusts, which look as if they had been stuck on. 
Sometimes they become confluent, and a considerable area 
of scab is produced, but the characteristic spots are generally 
recognizable at the borders of the patch. Each spot runs its 
course in a week or ten days. The skin is quite superficially 
affected. There is no deep infiltration, and the spots are 
not painful, and when the scab drops off a reddened, desqua- 
mating surface is left, but no ulceration except in strumous 
and unhealthy subjects. Dr. Tilbury Fox could not find 
any fungus in the vesicles, but only later on in the crusts, 
stating that this is an accidental occurrence. However, 

1 Dr. T. P. Foster has described a mild and abortive form of 
contagious impetigo under the name herpes contagiosus 'varioli- 
formis, in which there was not any initial fever, and in which 
there was a marked papular stage, and multiformity of eruption 
present. 



128 THE DETAILED DESCRIPTION 

other dermatologists have recorded its presence, but these ob- 
servers differ widely in their descriptions amongst themselves, 
and some of the cases were certainly not true examples of 
this affection. The usual sites first occupied by the eruption 
are the face, the hands, and sometimes the head, and more 
rarely the body; but wherever it first appears it is generally 
inoculated in other parts by scratching. The mucous mem- 
brane and the conjunctivae are not infrequently implicated. 
The extent of surface attacked, however, is very varied. 
Lastly, although all parts of the eruption do not evolve 
simultaneously, the appearance of the disease is very uni- 
form, and the disease tends to run a definite course. 

Diagnosis "The direct guides to the disease are its 

apparently epidemic character in many cases ; its attacking 
children, perhaps several in a family ; the antecedent pyrex- 
ia! affection of the general system, clearly of acute produc- 
tion ; the presence of the isolated, flattened, light-colored, 
< stuck-on' scabs, replacing flattened bullae, which have de- 
veloped from well-formed vesicles ; the uniformity of the 
eruption ; the eminently contagious nature, and the inocula- 
bility of the secretion ; the absence of pain and any itching 
of consequence, save occasionally at the outset." There are 
several diseases with which it might be confounded by the 
inexperienced, and amongst the least likely are pemphigus, 
hydroa bulleux, varicella, and, when on the legs, ecthyma. 
Pustular scabies may offer more difficulty in some cases about 
the legs and arms. But it is with eczema impetiginodes 
that confusion is generally made. It is distinguished from 
the latter by the acute febrile movement, the site, the ab- 
sence of infiltration of the skin, its easy cure, the character 
of the crusts, its definite duration, the discrete arrangement 
of the crusts, and the constitutional condition. The diffi- 
culty, however, exists in the confluent cases of impetigo 
contagiosa, and especially where it occurs about the head. 
Pustular eczema, too, is undoubtedly inoculable from place 



OF CUTANEOUS DISEASES. 129 

to place. Attention to the character given, and observance 
of the disease at the borders of the confluent patches, will 
generally solve the difficulty where such exists. 

Treatment The scabs should be removed by bathing or 

oiling, when it is only necessary to apply to the part beneath 
a weak ammonio-chloride of mercury ointment (gr. v to ^j) 
night and morning, for a few days, and the eruption will 
generally speedily disappear. Occasionally the healing up of 
the spots is delayed by ill-health, and in this case a little 
quinine and steel will be found useful in conjunction with 
some slight aperient. 

Intertrigo, see Erythema. 

Iodide of Potassium Rash is chiefly of two kinds, the 
acneiform and the bulliform ; but it also produces purpura. 
In many patients iodide of potassium excites a rash which is 
not distinguishable from common pustular acne, save that it 
is not confined to the face, but is distributed irregularly in 
different parts of the body. This rash may be so inflamma- 
tory as to appear ecthymatous. The drug may also excite 
what seems at first sight to be a true bullous eruption, in con- 
nection with much general depression, ulceration of the 
tongue, and large fungatory sores originating apparently in 
the bullae, which often freely crust before ulceration. But 
these so-called bullae begin as hard, painful papulae, and are, 
I believe, seated at the hair follicles. The iodide stimulates 
the glands, and the effusion of fluid sebum intermixed with 
serum is so free and rapid that the essentially acneiform or 
follicular character of the rash is lost in the quasi bullae 
which result. These so-called bullae are very tense, painful, 
and feel solid. They have very solid bases, often exude a 
thick, creamy, pus-like (?) fluid, and after bursting their 
base fungates into a large, raised, grayish-yellow papillated 
mass, which on healing away leaves a decided scar. Such 



130 THE DETAILED DESCRIPTION 

cases are very rare indeed, and they occur in exceptional 
instances -where persons have a peculiar idiosyncrasy as 
regards iodide of potassium. A few doses of the drug given 
for four days may excite this latter rash, and it will rapidly 
disappear when the drug is given up. (See Ghir. Soc. Trans., 
for a communication, with illustration, by Dr. Tilbury Fox.) 
It is also said to excite a purely bullous eruption undistin- 
guishable from pemphigus occurring in the uncovered parts 
of the body especially. 

Itch, see Scabies. 

Keloid is a hypertrophic outgrowth of the fibro-cellular 
tissue of the skin. There are two forms, the idiopathic and 
the traumatic, the latter originating in an excessive growth 
of the tissue of a scar following the use of the surgeon's knife, 
or the applications of acids and the like. In the idiopathic 
form, a firm, prominent, palish-colored nodule appears on 
the skin and sends out processes, as it were, from its periph- 
ery, which by their contraction pucker in the skin around 
towards the central mass. The contractility of the keloid 
tissue indeed is characteristic. 

Treatment consists in avoiding all irritation of the keloid 
growths. If removed they recur. 

Kerion, see Tinea kerion. 

Lepra is an old term for psoriasis, and especially that 
form which consists of circular rings of disease. 

Leueoderma {Pigment Absence) This term is applied 

to the condition presented by the skin when there is a dimi- 
nution in the normal amount of pigment, whether congenital 
or acquired, local or universal, when unassociated with any 
textural changes. 



OF CUTANEOUS DISEASES. 131 

Albinismus When the pigment is congenitally, univer- 
sally absent, the state is called albinism, and it may occur 
in all races, though affirmed to be more common in some 
countries than others. Albinism persists through life, and 
the deficiency of pigment, beyond rendering the skin very 
sensitive and the eyes unable to bear a strong light, is not 
associated with any constitutional conditions beyond some 
delicacy. Albinos may be born of normally pigmented 
parents, but how far the converse is true is not well known. 
Besides this universal condition, a local deficiency of pig- 
ment is met with as a congenital condition, certainly amongst 
negroes. 

Leucoderma proper (the Vitiligo of Hebra) is applied, in 
a more limited sense, to the acquired forms. An unimport- 
ant variety may follow prolonged pressure, burns, or other 
injury, or textural alterations of the skin. Another very 
common and striking variety occurs in dark races, and 
causes the subjects of it to assume a piebald appearance. 
It may ensue upon illness, and often undergoes increase and 
diminution with varying health. In a third variety, met 
with amongst fair races, there, is not only a deficiency of 
pigment in circular or oval, detached patches, but an in- 
creased deposition in the immediate neighborhood. In fact, 
the appearance presented is as if the pigment had been re- 
moved from the centre of a patch to the periphery. It is 
important to notice, for diagnostic purposes in extensive 
cases, that in these patients the white patches present a well- 
defined convex border to the peripheral pigment, and the 
latter a concave border to the white patch, also that there is 
no textural alteration, secreting function, or sensation per- 
version. This form of leucoderma may be local or very 
extensive, and involve the hairy parts, it is usually tolerably 
symmetrical, and occurs in people of dark complexion. Age 
and sex have no influence, but it is rare in children. There 
is generally no special dyscrasia, but it occurs in individuals 



132 THE DETAILED DESCRIPTION 

who are not very vigorous. Sometimes, however, there is 
distinctly faulty innervation, or it ensues on severe illness. 

The treatment is by cod-liver oil and tonics. Locally, it 
is generally useless and inadvisable to meddle, but stimu- 
lants, such as mustard and cantharides, are occasionally 
used. 

Lichen is a disease, the description of which is omitted 
by many writers under the belief that it is a species of ec- 
zema, but there is an independent disease to which the term 
has been long applied in England. True lichen is charac- 
terized by the presence of solid pale fleshy papules about the 
size of millet-seeds, which preserve their characters as pa- 
pules throughout their existence, and are accompanied by 
marked itching. The skin generally, moreover, is usually 
dry, somewhat thickened, and often of muddy aspect. The 
eruption may appear in the form of very pale, flesh-colored 
and scattered papules (Z. simplex), attacking one or more 
regions, or even the greater part of the trunk, and more 
rarely about the extremities : sometimes as groups of papules 
(Z>. circumscriptus). Often the lichen attacks the backs of 
the hands, which may, secondarily , become inflamed and 
give out a discharge (L. agrius). The disease in this situa- 
tion is excited by the contact of irritants, as sugar and flour, 
and then bears the name of Grocers' or Bakers' itch (vide 
these), and under these circumstances the eczematous com- 
plication becomes the chief trouble. If the lichen papules 
are seated at the hair follicles, giving the surface a dotted, or, 
even, on a small scale, a rasp-like appearance, the name L. 
pilaris is given ; but this term is also made to include not 
only inflammatory infiltration around the hair follicle, but 
also that condition in which papules are produced by the 
choking of the follicles by epithelial exuviee or sebum, 
which occurs in persons whose skin is inactive. So-called 
L. lividus is a purpura ; that is to say, there are little hem- 



OF CUTANEOUS DISEASES. 133 

orrhagic papules formed. Of late years, dermatologists have 
with some approach to unanimity recognized two other forms 
of lichen, first described by Hebra, viz., Lichen ruber (which 
includes the Lichen 'planus of Wilson), and L. scro- 
fulosorum. L^ichen planus, as described by Wilson, con- 
sists of solid, red papules of very special features, which stud 
various parts of the surface symmetrically, the front of the 
forearms, especially the wrists, the flanks, the abdomen, the 
hips, and the legs below the knees. These papules attain 
the size of a large pin's head or more, and are dull red, an- 
gular at their bases, flat at top, with u peculiar shiny or 
glazed aspect, and umbilicated more or less distinctly. At 
first they are discrete, but they group together into patches 
by the springing up of new papules between the old. Then 
the patch becomes red, infiltrated, and slightly scaly, and 
presents the aspect of psoriasis, for which the disease is fre- 
quently mistaken, but it is distinctly papular at the edge. 
Dull, colored stains are left on the disappearance of patches 
or papules. The disease is accompanied by a severe burning 
sensation, or itching, and the patients attacked are usually 
much out of health. In some cases the surface of the body 
is more or less generally involved ; but as the rule, while the 
papules are not so large as in lichen planus, they are more 
confluent, or rather, patches occupying the whole regions are 
formed. Accompanying the rash there are also marked hyper- 
emia, itching, and more rarely considerable marasmus, ner- 
vous irritability, and like symptoms. There are all stages 
between lichen planus and lichen ruber, and the latter ex- 
hibits in places the characteristic discrete papular rash of 
the former. This severer phase is rare in England ; it is 
the L. ruber of Hebra, but the two conditions are different 
degrees of the same disease. Hebra has also correctly de- 
scribed a L. scrofulosorum, which occurs in those who ex- 
hibit decided signs of scrofula. The eruption is made up of 
circular groups of little pale papules the size of millet-seeds, 
12 



134 THE DETAILED DESCRIPTION 

each having in its centre a little exuvial plug. There is no 
itching. If the disease be severe, acneiform pustules may 
develop interspersed with the papular rash. It attacks, by 
preference, the trunk. 

Diagnosis — We need only refer to lichen ruber. Its 
itching and the presence of its papules on the forearm should 
not mislead to the idea of its being scabies. The papules 
are so very characteristic that they should be recognized at 
once by their flatness, irregularity, and glazed appearance. 
When patchy the disease may be thought to be psoriasis, 
but the presence of characteristic papules again, and the 
" papular" origin of the rash, and the presence of very thin 
pus, and not silvery scales, distinguish lichen planus or ruber. 
We have known the two aspects of the disease mistaken 
again and again for a syphilitic disease, but this arises from 
ignorance of the existence of such a malady as lichen planus. 
The papules of syphilis are wholly unlike those of lichen 
planus, which lack all concomitant evidences of syphilis. 

Treatment Lichen simplex and circumscriptus must be 

treated as simple inflammations. A loaded system, pyrexial 
condition, or debility should be attended to, but alkalies should 
also be exhibited in some form or other. Should the disease 
not speedily disappear, a mild mercurial course, or one of 
Donovan's solution, may be given together with cod-liver oil. 
Locally alkaline and gelatine baths, with remedies to allay 
irritation, are needed, as (14), (16), (20), (23), (24), (30), 
(32), (37), (38), (47). Lichen agrius must be dealt with 
as an eczema rubrum. In L. planus the indications, as re- 
gards internal treatment, are to improve the tone of the 
nervous system by rest, change of air, and general tonics, 
including arsenic, but especially the mineral acids and bit- 
ters ; to alleviate dyspeptic troubles ; to feed up the patient ; 
and lastly, to attempt to diminish hyperemia by astringents, 
such as perchloride of iron. As regards local medication it 
is needful to allay irritation by gelatine and alkaline baths 



OP CUTANEOUS DISEASES. 135 

(la and lb), and by sedatives (23 et seq.); to diminish hy- 
peremia by the use of such remedies as (74), (14); and, 
finally, to promote the absorption of the papules, especially 
by vapor baths, and cautiously employed tarry compounds. 
In the severer aspect of the disease termed lichen ruber, 
arsenic may do good, but we have not found it efficacious. 
There is considerable nervous excitability, and sedatives 
may be required, but the general treatment is the same as 
that for lichen planus. 

Lichen urticatis, see Urticaria. 

Lupus is a disease characterized by the formation in the 
skin of a neoplasm or new growth, whose minute characters 
are those of granulation tissue, and which occurs in the form 
of a diffused infiltration, or of tubercles. This new growth 
tends to invade and destroy the true skin textures, the corium, 
the glands, and the vessels, etc., and to undergo, in effecting 
these changes, degeneration itself, so that all that is left be- 
hind where the disease has had full play is cicatrized tissue. 

There are two main varieties of lupus termed respectively 
L. erythematodes and L. vulgaris, the main difference being 
that in the former the sebaceous glands are especially and 
primarily implicated, whilst the new growth occurs in a dif- 
fused form ; and in the latter the growth arises in the corium 
tissue itself, and occurs in nodules or tubercles from the outset. 

L. erythematodes is the term applied, as just indicated, 
to the superficial lupus in which the sebaceous glands are 
especially implicated, and comedo-like spots, indicative of the 
irritation, infiltration, and choking of these glands and their 
ducts by secretion, stud the otherwise reddened and some- 
what raised surface, which is also affected by the new growth. 
The disease attacks by preference the face, and especially 
the nose and cheeks of young women of lymphatic tempera- 
ment, but it is also seen on the scalp, fingers, and, more rarely, 



136 THE DETAILED DESCRIPTION 

in other parts of the body. It begins about the time of 
puberty ; it is more common in women than men ; runs a 
very indolent course, and is rebellious to treatment. 

In its most common seat, the face, it begins frequently like 
an erythema, or the disease may assume the aspect of a slight 
seborrhoea. The patches are often very small, and there 
may be one or several. Under the eye is the favorite locality. 
This erythema or seborrhoea may at first disappear, but soon 
returns, and then it assumes an obstinacy which does not 
belong to either of these two conditions above named, and 
this feature attracts attention. The patches are more or less 
circular, very well denned ; their edges raised, and thin ad- 
herent scales form upon them, or the comedo-like bodies make 
their appearance ; and at this stage, which is an early one, 
the deeper tissues of the affected part seem to have thinned 
a little — in fact atrophy sets in. This settles the diagnosis 
at once. As the disease progresses, the centre sinks from 
increasing atrophy, becomes paler, and now, if not before, the 
orifices of the sebaceous ducts are very patulous and distinct, 
the patches enlarge, and if near coalesce. Often there is a 
patch under each eye, and if these bridge together and form a 
junction over the nose, the appearance of a butterfly is pro- 
duced, hence the term butterfly lupus. 

When the hands are affected, the patches look like chil- 
blains in slight cases, but the disease may occur in summer. 
In marked cases atrophy is always present. When the scalp 
is affected, there is at first a red infiltration covered by adhe- 
rent scales, and then the tissues atrophy, and become white 
in aspect, like cicatricial tissue, whilst the hair is lost, and 
baldness of course results. 

The subjective symptoms are limited to itching and burn- 
ing. The general health is sometimes good, but mostly 
feeble and unsatisfactory. We have described a dissemi- 
nated, follicular lupus simulating acne (see Lancet, 1878). 



OF CUTANEOUS DISEASES. 131 

Lupus Vulgaris. — In this disease the neoplasm takes 
the form of red, or at first yellowish, solid, more or less 
elevated, surfaces, varying in size from a small pea to very 
large areas, due to the growth or coalescence of different 
points or patches of disease. The morbid growth is elevated 
above the surface, and is a well-defined outline ; as the rule, 
it is covered over by a thin layer of adherent cuticle, which 
generally gives the growth a slightly scaly aspect, and ves- 
sels are seen to course over and about the tubercles before 
ulceration has set in. The neoplasm, which has a semi-gela- 
tinous aspect when fully grown up, originates in the corium, 
spreads upwards and outwards and more or less deeply, and 
destroys in its increase the normal textures so as to induce 
their atrophy and disappearance. Scarred tissue is left be- 
hind, it is thick, whitish, glistening, and shows little dispo- 
sition to contract. If the lupus tissue be removed by insen- 
sible absorption, commencing with its degeneration, there is 
no ulceration. If it break down freely, ulceration occurs 
prior to cicatrization. The disease is attended by itching at 
times, and perhaps some pain in the ulcerative stage. It 
begins at an early age, generally about puberty ; attacks the 
face by preference, especially the nose, cheek, and ears, but 
it also occurs on the trunk and extremities. It occurs in 
lymphatic and strumous subjects. 

There are no true varieties in reality, the so-called varieties 
are, clinically speaking, different phases of the same disease. 
If the lupus consist of tubercles scattered or crowded into a 
patch, the disease is termed L. tuberculosus, which may or may 
not in later stages ulcerate, hence the terms L. exedens and 
non-exedens. If the disease present the aspect of a general 
infiltration, followed by thinning of the textures and marked 
scaliness, it is termed L. exfoliativus. If there be much 
thickening and elevation, due to concomitant increase of the 
connective tissue elements, the disease is termed L, hyper- 
trophicus. In scrofulous persons the ulceration is free, and 

13* 



138 THE DETAILED DESCRIPTION 

large, dark, heaped-up crusts form, hence the unnecessary 
term L. scrofulosis. 

Diagnosis It will suffice to make an easy diagnosis, in a 

large number of cases where a doubt may exist as to the 
disease possibly being syphilitic, if it be remembered that in 
lupus the skin trouble stands alone as the total disease, and 
that there is an entire absence of any of the ordinary con- 
comitances of syphilis, nor is the skin mischief multiform 
in the character of its essential lesions. 

Treatment Lupus erythematodes is often difficult of cure. 

The lightest cases may be remedied by cod-liver oil, liberal 
diet, and iron internally, and painting constantly with liq. 
plumbi, or iodide of starch paste (vide formula). Severer 
cases are better treated with mercurial plaster, tarry appli- 
cations, tincture of iodine, or a strong solution used once 
or twice a day. If these fail a solution of caustic potash 
and water in equal parts, the fuming, acid nitrate of 
mercury, Vienna paste, and other caustics are serviceable, 
and they must be re-applied till proper cicatricial tissue re- 
sults after the healing of the caustic wound, which should be 
accomplished by dressings with unguentum diachyli after each 
application of caustic. Lately, scooping and scarification, 
or multiple puncturing of the diseased surface have been re- 
commended, but these do not, we think, offer superior advan- 
tages. In obstinate cases, perhaps, strong iodine 2 or arseni- 
cal caustics are the best, but must be used with due caution. 

In the case of lupus vulgaris the same principles of treat- 
ment apply, whilst the general health is to be improved in 
every way, and especially in strumous subjects, by cod-liver 
oil, iron, fresh air, seaside change, a full milk and fatty diet, 
and the like ; the essential point of moment is to destroy the 
new growth by caustics repeatedly applied, but not so as to 
produce unnecessary cicatrization. Great care is necessary 
in the application of these remedies, and judgment in the 
selection of appropriate times and cases. Whenever a lupus 



OP CUTANEOUS DISEASES. 139 

is very tender, or shows a tendency to spread rapidly, or be- 
comes hyperasmic under slight causes, caustics should not be 
used, but they are particularly indicated when the disease is 
indolent. When the lupus is red, tender, and irritable, it is 
useful to exclude the air, and paint once or twice a day with 
liquor plumbi for some time. The caustics most suitable are 
(5) and (9), and it is best to use them to the edges of the 
patches in the first instance, and apply a poultice if there is 
much pain. The caustic may be repeated at intervals till an 
apparently healthy surface appears, and one that seems in- 
clined to heal. The surface should then be dressed with 
some simple astringent, as (74) or (35). When lupus patients 
are out of health, they should take appropriate tonics, iron, 
especially cod-liver oil, and quinine. The slighter forms of lu- 
pus may often be cured by the application of astringents only. 

Maculae. — There are four chief forms — viz. : (1) The 
pigmentary, occurring idiopathically as in leucoderma and 
melanoderma, or symptomatically in connection with uterine 
excitation, and certain cachexise, or after certain eruptions 
{see Pigment increase) ; (2) the parasitic, as in tinea versi- 
color ; (3) the chemical, due to the use of nitrate of silver ; 
(4) the hemorrhagic, as in purpura (see the special descrip- 
tions of the diseases here named). 

Medicinal Rashes. — Some medicines when taken in- 
ternally bring out on the skin an efflorescence, a fact which 
it is well to be acquainted with. Thus Arsenic is said to ex- 
cite in rare instances Herpes zoster, and to lead to indura- 
tion of the palms of the hands. Iodide of Potassium may 
induce an acne, and very rarely a bullous eruption, with 
fever and great constitutional disturbance (see Iodide of 
Potassium Hash). Bromide of Potassium excites a some- 
what similar acne, as well as other phases of eruption due to 
inflammation of the sebaceous glands (see Bromide of Potas- 
sium Eruption). It is not very unusual to meet, whilst ad- 



140 THE DETAILED DESCRIPTION 

ministering Copaiba, with a raised, red, uniform, terribly 
pruritic, hypersemic rash, which now and then goes on to 
vesiculation. It attacks the arms in chief measure. Scarla- 
tiniform eruptions have been met with also during the exhi- 
bition of Chloral, Salicylate of Soda, belladonna, Morphia, 
but they must be looked upon as of very exceptional occur- 
rence. Quinine eruptions have been recorded a considera- 
ble number of times now, and they assume usually a scarla- 
tiniform or urticarial aspect. 

The external applications of various drugs and vegetable 
juices are well known to produce eruptions. We need not 
refer to the causation of blisters and ulcers by caustics, etc. 
Arsenic commonly excites an inflammation of the skin, and 
it is an active agent in giving rise to the erythema, papules, 
vesicles, pustules, and ulceration following the wearing of 
(a) articles of clothing brilliantly colored by the aniline 
dyes ; (b) green ball-wreaths, artificial flowers, etc. Many 
dyes, even apart from the arsenic, are capable of exciting a 
mild dermatitis. Stro?ig mercurial or tartar emetic oint- 
ments will occasion a pustular eruption, as will also Croton 
oil. Undiluted Arnica may cause very severe inflammation. 
Tar brings out an acne, and Sulphur a papular and then a 
vesicular eczema. 

Amongst the irritant juices of plants, which occasion an 
inflammation of the skin, that of the Nettle is well known. 
For America two species of Rhus (viz., the poisonous su- 
mach or dogwood, and the poison ivy or oak) excite in some 
persons, by contact or proximity to the plants, an erythema- 
tous though usually vesicular eruption of very extensive and 
often severe character. 

Miliaria is characterized by the formation in the skin 
of a soft, red, pruritic, pimply eruption, the papules of which 
it is made up rarely exceeding a pin's head or a millet seed 
in size. It is due to disordered action of the sweat glands, 



OP CUTANEOUS DISEASES. 141 

i. e v either from the overtaxing of their functions, or from 
the irritation of abnormal secretions. The excessive or sud- 
denly increased amount of sweat may be due to the influence 
of temperature, a special excitation of the glands, or the de- 
rangement of the vaso-motor system from debility. The 
textures immediately surrounding the gland and its duct are 
irritated and become hyperaemic, so that a soft red papule is 
produced. It is possible that this papule may be vesiculate 
in certain cases, but the vesicles which are so frequently 
found capping the papules, or intermingled with them, are 
sudaminal in nature. It should be remembered that the 
contents of the vesicles may become purulent. A severe 
form of Miliaria has already been described under the term 
Lichen tropicus. Although all regions of the body may be 
affected, those parts more specially subject are the trunk and 
neck and then the arms. It may appear suddenly and as 
quickly disappear. The summer is the season when Miliaria 
is more frequently met with, but it may occur in winter — for 
instance as a complication of Dysidrosis — and is not uncom- 
monly seen at all seasons on the bodies of persons in states 
of pyrexia where there is excessive sweating, e.g., in Phthi- 
sis and Rheumatism. 

Treatment — When met with as an accidental occurrence 
in the sweating of pyrexial states, it is of little importance ; 
also when seen in the summer months, when the hyper- 
aemic spots may only require a soothing calamine lotion. 
But in other states the causation of the Miliaria is due to a 
debilitated nervous system, and nervine and ferruginous 
tonics, etc., are indicated. 

Molluseum eontagiosum is a disease of fairly com- 
mon occurrence, in w r hich the sebaceous glands are enlarged 
and distended by an excessive quantity of sebum, so that 
soft, sessile, pearly or pinkish-looking, little round tumors, 
which resemble white currants or pearl buttons in rough 



142 THE DETAILED DESCRIPTION 

outline, are produced, which have the peculiarity of an um- 
bilication in the centre, disclosing the distended opening of 
the gland duct. They vary in size from a pin's point to 
a walnut, it is said ; but usually they average that of a 
good-sized pea. A white cheesy matter may be squeezed 
out from the opening, and the sac thus more or less emptied. 
The face is the chief seat of the disease, and it occurs 
mainly in children. There may be several or a great num- 
ber of these little tumors present in a given case. It is 
apparently semi-epidemic at times, and appears too to be 
contagious. 

If left alone the tumors generally suppurate, and then dis- 
appear, leaving cicatrices. 

The disease is of sebaceous origin clearly, and our own 
independent observations, recently made, have re-established 
this point. Lately it has been affirmed by Boeck, Lukowsky, 
and others, that the disease arises from a growth downwards 
of the interpapillary portions of the rete Malpighii, followed 
by degenerative changes in the central cells, and their ex- 
pulsion through a central aperture. We find that each 
tumor consists in hypertrophy of sebaceous glands, with 
increased rapid endogenous formation of cells, that become 
completely vacuolated and distended w r ith altered sebum, 
and form the concreted mass of contents. 

Diagnosis Molluscum contagiosum tumors are distin- 
guished from small fibromata by their central aperture, and 
the presence of sebum within them, which can be expressed 
readily. On the genitals they are commonly confounded 
with warts and condylomata, but the same points suffice for 
their distinction. 

Treatment., — This consists, in the early stage, of touching 
them with a point of caustic or the acid nitrate of mercury. 
If the tumors are of any size, their contents should be squeezed 
away, and the sac of the growth then touched with some 
mild caustic. 



OP CUTANEOUS DISEASES. 143 

Morphcea Synonymes, Addison's Keloid, and Cir- 
cumscribed Scleroderma (Fagge). — Attention was specially 
drawn to this disease by Addison as a form of keloid, and a 
well-defined position was accorded it by the excellent descrip- 
tion of Wilson in 1868. In America it has since been pretty 
generally recognized, but in Austria it is still confounded 
partly with anaesthetic leprosy, and, in the more severe 
forms, with scleroderma. Wilson also and others are in- 
clined to regard it as a remnant of leprosy left with us. It 
is a somewhat rare disease, and its appearance is so striking 
that when once seen the disease will probably be never for- 
gotten. It occurs at first in isolated patches, either single 
or multiple, and often extensively distributed ; these patches 
may subsequently coalesce into large areas. The patches 
are usually more or less rounded, but occasionally occur in 
irregular bands or stripes or even in lines and spots. In the 
common form (M. alba) the disease begins as a delicate pur- 
ple or lilac blush, which is temporarily diminished by pres- 
sure. A pale, slightly depressed area then becomes apparent 
in the centre of the blush, which is not an " erythema" in 
the ordinary sense, and gets more and more defined, whiter, 
denser, smoother, and more polished. Occasionally the 
cuticle desquamates slightly or becomes wrinkled like tissue 
paper. The central white surface gets less and less mottled 
by straggling venules, whilst the dilated veins become more 
apparent and the amount of blood supply increased around 
its edges, forming the characteristic lilac fringe. The patch 
may attain a size involving the whole surface of the mamma. 
It is in this condition that the patient usually comes under 
observation with the dirty alabaster, or bacon-fat looking, 
circumscribed patches, giving the notion of a piece of white 
wax having been let into the skin. In the rarer form (M. 
nigra) the diseased conditions are similar, but there is a 
varying degree of dark pigmentation of the patches simulating 
leucoderma. Evidently there is an overgrowth and condensa- 



144 THE DETAILED DESCRIPTION 

lion of the fibrous tissue, or an infiltration, which disturbs 
the circulation and causes the prominent superficial venules, 
and, as it increases and obliterates the bloodvessels, induces 
the condition seen immediately beyond the area of the dis- 
ease. As the disease progresses atrophic changes occur (M. 
atrophica), often to a considerable extent. The nerves of 
sensation are to some extent secondarily interfered with, 
producing differing degrees of anaesthesia. Whether the 
nerves play a more intimate part has not yet been demon- 
strated, but there is sometimes precedent pain, and, coinci- 
dently with the progress of the disease, generally either ting- 
ling, or burning, or slight itching, or numbness. The perspira- 
tory and sebaceous glands, and the formation of hair, are all 
interfered with in the patches. We have hardly material 
enough yet to argue as to its neurotic distribution, but it is 
rarely a symmetrical disease, and often confined to one part 
and one side of the body. Drs. Wilson, Tilbury Fox, and 
Duckworth have called attention to its situation over the 
course of the supra-orbital nerve, especially on the left side. 
In Wilson's cases the trunk, which includes the neck, was 
chiefly affected in 11 cases, the legs in 7, the arms in 6, the 
submammary region in 3. It may occur at any age except, 
perhaps, infants (Wilson mentions a case aged 4 years) and 
in old age. It is much more common in females than males, 
and is due to " a weakened trophic or nutritive power, and 
is a consequence of nutritive debility." It occurs in indi- 
viduals of weakly constitution, but may follow any debility, 
especially such as in women is associated with irregularities 
of menstruation, and pregnancy and lactation. 

Diagnosis Morphoea nigra may be easily distinguished 

from leucoderma by the textural changes. When occurring 
on the forehead and extending in the hair causing shedding of 
latter, it has been confounded with alopecia areata. In an- 
aesthetic leprosy the patches never present the curious wax- 
like condensation or infiltration of the skin, and the history 



OP CUTANEOUS DISEASES. 145 

of the patch is different. It is exceedingly difficult, if not im- 
possible, to distinguish many forms of morphoea and scleroder- 
ma, and it is held in England that morphoea is only a peculiar 
circumscribed form of scleroderma ; that the former may pass 
into the latter condition, and that clinical experience shows 
that the two forms are connected by a complete series of 
cases. In America this view is not so generally held {vide 
Scleroderma). 

Treatment. — The disease is essentially a very chronic one. 
" Slightly more than half the cases are curable," says "Wil- 
son, but we have obtained rather more favorable results. 
The patches may spontaneously resolve, but the cure is gen- 
erally very slowly brought about. Some cases get well and 
relapse, and in others the patches rapidly get more and more 
numerous in spite of all treatment until the body is covered. 
We advocate the administration of cod-liver oil, preparations 
of iron, quinine, nux vomica, phosphoric acid, the mineral 
acids, etc. Locally we do nothing, but Wilson advocates 
stimulants, such as aconite liniment, bichloride of mercury 
in almond emulsion, cantharides, etc., whilst Bulkley likes a 
mild mercurial ointment. 

Nails are subject to a variety of diseased conditions. 
The clubbing and striation, as an effect of exhausting ill- 
ness such as heart disease and phthisis, are well known, and 
also the transverse notching indicating the cessation of 
growth in the part during acute illness. The nails are ill- 
formed, and rendered opaque and brittle, and possibly 
thickened, in psoriasis, pityriasis rubra, lichen planus, and 
sometimes in ichthyosis. They are likewise stunted, and 
more or less atrophied in some cases of syphilis, and very 
frequently in those who are weak and out of health. The 
nail-bed, or matrix, often gets inflamed, with pain, heat, 
swelling, and suppuration, occasioning perhaps the loss of 
the nail. This is called onychia, and it may be syphilitic, 
13 



146 THE DETAILED DESCRIPTION 

strumous, or erysipelatous in origin. Lastly, the nails may 
be thickened and rendered brittle, and raised from their 
bed by the attack of fungi, and then the disease is known as 
onychomycosis. 

A few words may be added as regards the diagnosis of 
these several conditions. In psoriasis of the nails, all or 
most of the nails, of the hands, and perhaps the feet, are 
affected. They become at first speckled, then opaque, un- 
even, dull, and brittle, and the free edge splits up into sev- 
eral layers. The clue to the nature of the disease is almost 
invariably given by the existence of psoriasis about the 
body, and one method of treatment for the nail and surface 
disease may be followed out. Onychomycosis mostly occurs 
together with some form of tinea of the head or body. It 
may arise by a tinea circinata travelling from the finger to 
the nail, or the nail alone may be affected in those who have 
been attending to ringworm cases. No psoriasis can be 
found, moreover, on the body in these cases. The nail be- 
comes opaque and brittle about the base and sides ; then it 
thickens, is loosened away from its bed, and breaks up into 
layers. Generally in onychomycosis — and this is a very 
important point — only one nail is affected, and more rarely 
two, and only exceptionally more than that. The nails of 
the feet are healthy, or, in other words, onychomycosis only 
attacks the nails of the hand. When scrapings of the nail 
are examined, fungous elements will be detected. The treat- 
ment consists in soaking the nail in a sulphurous acid lotion 
(one part to three or four of water) constantly, and applying 
acetic acid every day or every other day, but short of produc- 
ing irritation. Syphilitic disease of the nails may consist in 
general atrophy or indolent inflammation. In the latter 
condition the parts at the base of the nail become painful, 
swollen, and red ; suppuration follows, and unhealthy ulcera- 
tion, with loosening and perhaps loss of the nail. Several 
fingers may be affected at one time. The diagnosis is ren- 
dered clear by the concomitance of other evidences of syphi- 



OP CUTANEOUS DISEASES. 147 

lis in the individual. The treatment consists in the applica- 
tion of black-wash externally and anti-syphilitic remedies 
internally. Onychia, when simple, is known by its acute 
onset and course, and the entire absence of syphilitic or 
strumous symptoms. The treatment is that of a sharp local 
inflammation ; nitrate of lead ointment is highly recom- 
mended for the disease. 

Pedieuli, see Phthiriasis. 

Peliosis Rheumatica, see Purpura. 

Pemphigus is a disease of very definite features, and 
needs no lengthened description. It is characterized by the 
occurrence of oval bladders or bullae, varying in size from a 
split pea to a pigeon's egg. These bullae are primary for- 
mations. Each bulla contains at first, and is distended by, 
a semi-transparent fluid ; soon, however, the fluid gets 
opaque, and the bulla becomes flaccid and dries up after a 
few days, leaving a slight scab, or giving rise to a superfi- 
cially excoriated surface, but no scars are left behind. The 
disease runs, as the general rule, a slow and chronic course, 
being prolonged by the development of successive crops of 
bullae. The disease, however, may be acute and pretty general, 
but in our experience the pemphigus is then connected with 
the development of a septicaemia or pyaemia, and in this case 
the skin trouble sinks into insignificance beside the graver 
general condition, but the skin eruption presents all the cha- 
racters of a freely disseminated pemphigus, hemorrhagic effu- 
sion into the bullae being a but infrequent accident. How- 
ever, in the great majority of cases, the disease is as stated, 
chronic and indolent. 

There are two main aspects of pemphigus, viz., P. vulga- 
ris and P. foliaceus. 

Pemphigus Vulgaris It may consist of a single 

bulla, which heals, to be replaced by another and another, 



148 THE DETAILED DESCRIPTION 

generally about the ankle or the hand. This is sometimes 
called P. solitarius, an unnecessary refinement. Usually 
there are a number of bullae scattered over a limb, on the 
abdomen, or indeed any part of the surface, except the scalp. 
The bullae are of varying size, oval or round, and in different 
stages in any given case. Here is a bulla, here a slight 
crusted spot, and there a stain. Bullae are attended perhaps 
by a little burning or itching, and may be a little painful at 
times, but they are not surrounded, as the rule, by any de- 
cided inflammatory areola. They may cluster or coalesce. 
They prolong the disease by their successive outbreak, each 
crop lasting a few days only. They may appear on the 
mucous surface also. The general health is not specifically 
disordered, except in the young and feeble, who become 
irritable, feverish, and weak. 

Occasionally there is intense irritation, and a pruriginous 
state of the skin complicates the pemphigus, which has this 
peculiarity, that, although it may begin by large, yet has also 
in this variety small, bullae. This is termed P. pruriginosis 
by some, but we think it a phase of hydroa (which see). 

Pemphigus Foliaceus is a rare condition, first de- 
scribed by Cazenave, but is a well-marked clinical variety. 
It attacks the body generally, beginning in one spot, and 
gradually invading the entire surface. The bullae are more 
or less abortive, and of course flaccid, and give rise to flaky 
incrustations, like thin, pie-crust flakes, covering the surface 
of the body, and presenting the aspect of a crusted eczema, 
only that bullae are detected. It is said to begin on the front 
of the chest. There are exceptions to this ; we have seen it 
begin on the back, and in one case just like ordinary pem- 
phigus of the limbs, with well-marked typical bullae. We 
have seen aortitis with it. The general condition is one of 
extreme prostration, and patients are specially worn out and 
exhausted by the irritation, burning, and free discharge that 
accompany the disease. 



OF CUTANEOUS DISEASES. 149 

Diagnosis Syphilitic pemphigus attacks especially the 

soles of the feet and palms of the hands of the newly born, 
and is associated with syphilitic cachexia and other evi- 
dence of syphilis. Bullae are secondarily formed in eczema 
of the hand, dysidrosis, and other diseases, but they are re- 
cognized to be not primary and independent, as are those of 
pemphigus vulgaris. 

Treatment -Local remedies play a subordinate part in 

the disease. The bullae may be punctured, and the affected 
parts treated with some soothing lotion containing oxide of 
zinc or Goulard's water with carbolic acid, or the surface may 
be dusted over with fuller's earth or some dusting powder, 
and when there are excoriations a mild, lead ointment may 
be used. In very severe cases, slight water packing or the 
continuous bath is recommended. But the internal treat- 
ment is of most good. Every possible source of debility 
must be carefully inquired after ; worry and excitement are 
to be avoided. The want of proper food, of fresh air, and 
of proper rest should be remedied, and the patient should 
be put upon a free and liberal course of quinine if there is 
any pyrexia or malarial condition present, though arsenic is 
preferred by many. In the foliaceous variety the patient 
should be dealt with as suffering from a rapidly exhausting 
disease. In children we have seen chemical food (solution 
of the hypophosphites of lime, iron, soda, and potassa) and 
cod-liver oil of great benefit. 

PhthiriasiSj formerly called prurigo senilis, is caused 
by the attack of the pediculus vestimenti. The disease con- 
sists, as we first pointed out some years ago, in the presence 
of certain peculiar hemorrhagic specks, together with the 
phenomena of secondary irritation induced by the pediculi 
and by scratching. It occurs chiefly in the aged, but it also 
is met with amongst younger persons, who are uncleanly. 
The pediculi attack the regions of the clavicles and neck, 

13* 



150 THE DETAILED DESCRIPTION 

first of all ; and it is there the first evidences of the disease 
must be traced. Pediculi do not bite as imagined. The 
characteristic lesion is easily overlooked. The hemorrhagic, 
mark is not raised like a scratched follicle, nor is it irregu- 
lar like an excoriation, but it is formed by the opening of a 
follicle dilated by the proboscis of the pediculis, showing in 
its centre a dried speck of blood which has welled up from 
its deeper part. It is a circular, cup-shaped depression 
about the size of the blunt point of an ordinary pin, and 
has an even and well-marked circumference. The pedi- 
culus inserts the proboscis into a pore, which it distends, and 
as the proboscis is withdrawn the blood wells up to fill the 
follicle. The irritation and scratching induce the develop- 
ment of papules, whose apices, when scratched off, become 
covered by scales of dried blood (pruriginous, as it is called). 
This condition, together with ecthymatous pustules, excori- 
ations from scratching, wheals, etc., constitute the secondary 
eruption of phthiriasis. At first the mischief is localized to 
the neck and shoulders, but presently it spreads over the 
back, abdomen, buttocks, etc. 

Treatment It consists in giving warm baths, smearing 

the skin with some parasiticide, as (114), (115), (124), to 
keep away the pediculi, and in carefully baking the clothes 
worn by the patients at a temperature of 220° F. 

Pigment Increase. — Moles; Lentigo; Chloasma; 
Melasma These terms include the states of increase of pig- 
ment in the skin which are unassociated with any textural 
alteration, and in the discussion of the subject it will be con- 
venient to follow Hebra, who has deduced something like 
order from the chaos of terms formerly in use. 

Moles are the pigmented areas of congenital origin. 
Those which are met with independently of any structural 
skin change are known as naevus spilus, and those associated 
with a slight amount of warty growth as naevus verrucosa. 
For other kinds of moles see the section on naevi. 



OF CUTANEOUS DISEASES. 151 

Lentigo. — Under this term is included " all those pigmen- 
tary changes which are usually met with on the face and on 
the arms, but also on other parts of the surface of the skin, 
in the form of spots of the size of a pin's head or lentil, and 
of a yellow, or yellowish-brown color." They are met with 
in children under the age of 6 to 8 years, whether they are 
much exposed to the sun or not, and they disappear almost 
invariably after 40. The brown spots known as ephelides 
or freckles, so common in red-haired persons, which are 
popularly supposed to be present only in the summer, really 
exist, as Hebra has shown, also in the winter, though in cold 
weather they are usually of a much fainter color. 

Chloasma This term has been widely used to denote 

also the parasitic disease now known as tinea versicolor, and 
the student is warned not to be confused by this in his read- 
ing. The so-called " liver spots" which come under this 
heading were named so from their resemblance to the color 
of the liver. Chloasma consists of yellowish or yellowish- 
brown patches, as distinguished from the spots above de- 
scribed, of various shapes, sharply defined, smooth, not 
detaching scales on scratching, and occurring anywhere on 
the body. Such pigmentation may result from any pro- 
longed irritation of the skin, from pressure, injury, blisters, 
and in uncovered parts from exposure to solar heat. We may 
here call attention to an unusual state of pigmentation occur- 
ring in lousy people, which is mentioned by Hebra, but spe- 
cially called attention to by Dr. Greenhow. 

Cases of another class are those symptomatic of some 
states of peculiar physiological activity or organic disease. 
The C. uterinum et gravidarum of females is widely known. 
It occurs in pregnancy, at the menstrual periods, and in dis- 
eased states of the uterus or disorders of its functions, is situ- 
ated about the nipples, abdomen and face, arching over the 
forehead pretty symmetrically, and is limited to the child- 
bearing period. 



152 THE DETAILED DESCRIPTION 

Apart from this special form there is a class of cases of in- 
creased pigmentation due to severe constitutional depression 
and more extensively diffused. It may follow or accompany 
severe illness, the cancerous cachexia, pellagra, etc. 

Melasma is the term applied when the pigmentation is very 
dark in color. A remarkable form is that met with in Addi- 
son's disease, and it is well to remember that it also occurred 
in the epidemic in Paris, some years ago, known as acrodynia. 

^Etiology This may be ascribed to faulty innervation, 

but very frequently it must be considered as simply a " freak 
of nature." 

Treatment. — When the cause lies in any apparent disor- 
dered state of the body, the object must be of course to rectify 
this, but, in the many slighter cases where the " blemish" 
is of a purely local nature, the removal of the pigmentation 
is not often very satisfactory, and hence the excuse for the 
multitude of cosmetics, etc., professing their removal. As 
the pigment molecules are situated in the lower layers of 
epidermic cells, we may dissolve or otherwise destroy these 
with the hope that in the new cells the pigment will be 
diminished, or we may stimulate the part with a view to 
their absorption. For this purpose lotions of borax, the al- 
kalies, spiritus saponis alkalinus, tincture of iodine, and cor- 
rosive sublimate are the proper agents to use. 

Hebra gives tincture of iodine painted on every four hours 
for three days ; or spiritus saponis alkalinus (cotton-wool 
kept applied wet). He also uses the following formulae: — • 

$. Bismuth, subnit., 

Hyd. amraon. chlor., aa 5ij 5 
Lard, ^j. M. 
S. To be applied on lint, at least at night. 

I£. Hyd. bichlor. gr. ^ ; 

Em uls. amygd. amarae, f§ij. M. 
S. Apply once or twice daily. 

I£. Hyd. bichlor. gr. v ; 

Sp. vin. rect. l'§j. M. 
S. To be quickly applied as a caustic. 



OF CUTANEOUS DISEASES. 153 

Pityriasis consists essentially in an hyper-production 
and excessive shedding of epithelial cells in the form of 
small bran-like scales or of flakes, as a 'primary and essen- 
tial phenomenon. This state is attended with more or less 
hyperaemia. It must be distinguished from secondary des- 
quamation, which follows as a consequence of all disturbances 
of the cutaneous circulation, or the epithelial formation of 
new growths and the like. It should be also recognized as 
different from so-called pityriasis of the scalp (dandruff), 
which is in reality a seborrhoea. The term pityriasis in the 
designation pityriasis versicolor, as applied to the vegetable 
parasitic disease tinea versicolor, is misleading. Simple 
pityriasis, as above defined, is usually the result of simple 
hyperaemia induced by irritants, such as cold winds, heat, 
friction, and is quite an unimportant matter. But there is a 
second variety, which is a well-marked and severe disease. 
It receives the name Pityriasis rubra. Some think this a 
phase of eczema ; we do not. The disease begins at one 
particular part of the body as a red scaly spot, and then 
rapidly spreads so as to speedily involve the whole surface of 
the body. When the disease is thus fully developed the 
face looks more or less flushed, and is sometimes covered by 
minute scales, the scalp is in a similar condition, but the 
body and limbs show the disease in its most typical features. 
The skin is intensely red, but the hyperaemia is greatly di- 
minished or disappears under pressure. The skin itself is 
not thickened by infiltration in the earlier stages of the dis- 
ease, but only secondarily and exceptionally so in the later 
stage of chronic cases. The surface also does not weep, as 
does that of eczema, except again very exceptionally. Upon 
this reddened skin are disposed oftentimes in layers arranged 
like the tiles of a house, or more or less irregularly imbri- 
cated, thinnish scales of epidermis, loosely adherent to the 
surface, and varying much in size up to large flakes an inch 
or more in diameter. These flakes are adherent in part, 



154 THE DETAILED DESCRIPTION 

but free at one or more points or edges. They readily curl 
up, and are easily, detached, and indeed large quantities are 
constantly and rapidly shed in some cases, so that two or 
three handfuls may be collected from the bed in the twenty- 
four hours, hence the term Dermatitis exfoliativa applied to 
the disease in this aspect. The patient suffers little discom- 
fort except in severe cases, when itching and burning and 
much stiffness are complained of, finally the disease is allowed 
to become chronic from want of proper treatment. In many 
cases it can be conducted through an acute course. Patients 
are usually much debilitated. 

Treatment — The slighter forms are relieved by internal 
tonics and the inunction of oil or some slight astringent. 
P. rubra must be treated as a disease consisting in general 
hyperemia of the skin due to nerve paresis. The patient 
must be wrapped in oil, and quinine and cod-liver oil must be 
given after the free exhibition of diuretics, to relieve the 
hyperaemic skin. Finally, perchloride of iron will be found 
very useful as convalescence approaches. 

Porrigo, a term now obsolete, but formerly applied in- 
discriminately to any crusted eruption or scaly incrustation, 
especially about the face or head. It included favus, ring- 
worm, eczema, etc. 

Prickly Heat, or Lichen Tropicus, occurs in the 
tropics mostly, but in a milder form elsewhere in the sum- 
mer months. It is seen as a minute, red, very itchy, pimply 
rash, due in part to inflamed sweat follicles and to hyperaemic 
papillae, which occur, we hold, secondarily to the other condi- 
tion. Lichen tropicus attacks the surface of the body, the 
limbs, and often the face, and is interspersed with sudamina, 
here and there. The itching is increased by heat, drinking 
hot liquids, etc. Much difference of opinion exists as to its 
anatomical seat. To those who are interested in the matter 



OF CUTANEOUS DISEASES. 155 

we commend the clinical observations on the disease con- 
tained in the report of Dr. Farquhar and ourselves on en- 
demic skin diseases of hot climates. 

Treatment. — This consists in giving diuretics freely : avoid- 
ing all stimulants ; wearing thin clothing : taking light food : 
using alkaline baths ; and smearing the surface with whiting 
made into a thin paste, or some simple emollients. 

Prurigo must not be confounded with Phthiriasis, which 
is an eruption due to the attack of body lice. Prurigo is 
a rare disease, and is characterized by the development of 
small, hard, pale, or flesh-colored papules, which in their 
early stage are better felt than seen, accompanied by in- 
tolerable itching. The papular rash is primary in prurigo, 
and is not a secondary condition. The papules are due to 
chronic inflammatory changes in the papillary layer of the 
derma, and sometimes the deeper stratum of the skin. They 
occur mostly on the lower limbs, buttocks, lower part of the 
abdomen, and outer part of the forearms. The disease in 
its mildest form, when it resembles lichen simplex of chronic 
character, is termed P. mitis, since the papules are small or 
limited in extent, and the itching is not severe. When the 
disease is well marked, the papules crowd together in certain 
situations, and even form small patches, especially on the 
legs ; they are felt under the skin before being clearly dis- 
cernible to the eye, and the itching or disordered sensation, 
termed formication, is like creeping of ants. To this condition 
the term P. for mi cans is given. In certain cases where the 
disease is extensive, and more or less congenital and persist- 
ent, it is called P. agria or ferox. More acute inflamma- 
tory changes however supervene, and then more or less sup- 
puration occurs in this variety, with glandular enlargements 
in the groin, whilst the skin feels thickened and indurated 
in the chronic stage. In England the severer form is not 
common. The writer has only met with a few cases : and 



156 THE DETAILED DESCRIPTION 

the disease of milder type has occurred in his experience in 
those exposed to alternate heat and cold in their occupation, 
and who have become debilitated. 

It is most important to thoroughly understand what is 
meant by the term pruriginous, which is so frequently used. 
In the first place it is most erroneously applied synonymously 
with the term pruritic. A consequence of pruritis is, that 
the skin gets scratched and excoriated, and, secondarily, the 
follicles become hyperaemic, and papules form, which in their 
turn get scratched and surmounted by a tiny blood crust. 
(See Follicular hyperemia.) Secondly, primary eruptions 
of various kinds are pruritic, and hence get scratched, and 
secondary lesions are formed. It is manifest that the term 
pruriginous is out of place as applied to these phases of dis- 
ease, and should only be used as denoting a distinct primary 
affection of a special nature. 

Treatment — Locally, to relieve the itching, our resources 
will often be severely taxed, and recourse must be had to the 
employment of vapor and alkaline baths, the use of sedative 
lotions, such as (23), (30), (34), (69), (71), (74), or to such 
applications as the lotio picis alkalinus. Internally, the ob- 
ject should be to improve the general health, and cod-liver 
oil and arsenic (90 et seq.), or (106) will be often found of 
especial service. 

Pruritus, or itching, is simply a disorder of sensation, 
and is an accompaniment of most skin diseases, especially 
eczema, lichen, prurigo, urticaria, scabies, and phthiriasis. 
Pruritus however may arise in the skin without any eruption, 
and then it is usually due to the circulation of some acridity, 
as bile products, urea, uric acid, etc. ; or to some local dis- 
order of the nerves ; or it is excited by some local irritant, 
as for instance, about the rectum by ascarides, about the 
head and pubes by pediculi, about the body by flannel, fric- 
tion, or scratching. It must be remembered that the ap- 



OF CUTANEOUS DISEASES. 157 

pearance of the skin is always altered by scratching, which 
causes follicles and papillae to become hyperaemic and promi- 
nent, their apices get torn off, and a drop of blood sometimes 
exudes and dries as a speck. This pruritic rash is often most 
erroneously termed prurigo (which see). In old people pru- 
ritus senilis occurs as an hyperesthesia consequent upon the 
general atrophy of the skin ; but in such persons the causes 
mentioned above may also come specially into play. 

The following hints relative to the more common causes 
of itching may be found useful. Itching increased at night 
by the warmth of the bed, with a pimply rash about the front 
of the arms and the body, is suggestive of scabies, in which 
case cuniculi are to be looked for. Itching in old people 
about the shoulders and back, may mean phthiriasis. At the 
back of the head in children, the evidence of pediculi is 
often revealed by an abundance of " nits" on the hair. Itch- 
ing, with eruption about the fork of the thighs, may be due 
to parasitic disease and intertrigo (ex., eczema margina- 
tum). Itching of capricious character, suddenly coming 
and going, here and there, especially at night, and without 
visible eruption in the daytime, is suspicious of urticaria, 
and the occurrence of "wheals" affords the means of a 
speedy diagnosis. In the winter time especially, it is not 
uncommon for the skin in certain persons to be irritable, par- 
ticularly towards evening, or when the clothes are taken off, 
and the air obtains access to the skin. The itching in such 
cases has been termed pruritus hiemalis, or winter pruritus, 
by Dr. Duhring. It occurs in various parts of the body, but 
more especially about the thighs and legs. In some cases 
no eruption can be seen, but in others there is decided tur- 
gescence and prominence of the hair follicles, enough in de- 
gree, perhaps, to constitute lichen pilaris. The disease is 
supposed to be " neurotic," but it is probably due to inac- 
tivity of the perspiratory function in the majority of cases ; 
at the same time there is frequently defective excretion of 
14 



158 THE DETAILED DESCRIPTION 

nitrogenous matters and bile products, at least in our expe- 
rience in England. It is not exclusively a winter affection, 
though most common at that time, because of the inactivity 
of the skin. Scratching, it must be remembered, may excite 
lichen, eczema, ecthyma, and the like, whereby the primary 
disorder may be masked. 

Treatment A number of remedies for itching occurring 

in connection with particular diseases, will be found in for- 
mulae (18) to (44), and scattered elsewhere. Starch, borax, 
or alkaline baths should be administered when the skin is hy- 
perremic or irritable, and in the early stages of pruritic mis- 
chief. In the indolent aspect, or later stages, sulphuret of 
potassium or mineral acid baths are of decided efficacy, and 
we have found salicylic acid lotion of great service. As re- 
gards internal treatment, this varies with the case. Itching 
due to the circulation of retained excreta may be relieved by 
appropriate aperient and alkaline remedies, whilst nervine 
tonics will be suitable for the "neurotic" itching. In our 
experience a "gouty" tendency, constipation, rich foods, 
and the free use of wine, have much to do with a great num- 
ber of cases of itching of the skin. All parasites, and other 
local irritants, must be destroyed or removed (see 209 et seq.), 
and flannel especially should not be allowed in contact with 
the skin in severe pruritus. Further information will be 
gathered from the special descriptions of the several diseases 
mentioned herein, with which itching is associated. 

Psoriasis consists essentially in an overgrowth of the 
Malpighian and cuticular layers of the skin, occurring more 
or less generally and in patchy form, over the surface, in 
association with hyperemia and engorgement of the vessels 
in the more superficial strata of the corium, and particularly 
its papillary portions in the atfected spots. It has generally 
been held that the hypertrophy of the rete and horny layers 
is dependent upon the hyperemia, but we have been singu- 



Or CUTANEOUS DISEASES. 159 

lar in maintaining for several years, in class and in our 
writings, the view that the changes in psoriasis originate, 
as regards the skin, primarily, or immediately, in the cell 
elements of the cuticle themselves. We were led to this 
conclusion by clinical observation, and an examination of the 
data afforded by the microscopic observations of Neumann 
especially ; interpreting these latter, however, in a different 
sense from Neumann himself, whose view is in accord with 
commonly received opinion. Recently Dr. Robinson, of 
New York, has published an admirable paper on the histol- 
ogy of psoriasis, in which, as the result of researches he has 
made, he comes to the conclusion so long held by ourselves. 
We may add that we have confirmed, during a recent inves- 
tigation, the correctness in the main of Dr. Robinson's his- 
tological data. 

In psoriasis as a consequence of the excessive growth of 
the cuticular layer of the skin, the surface of the psoriasis 
assumes a marked scaly appearance due to the accumulation 
and heaping together of the abnormal quantity of epithelial 
scales. And these scales have this characteristic, that they 
are dry and of very silvery aspect in the mass, which mostly 
enables the disease to be at once recognized. Psoriasis, 
therefore, is made up of elevated points or patches of hyper- 
aemic cutis, upon which are seated masses of silvery-white, 
dry scales. If these masses of scales are forcibly removed 
there is this peculiarity also observed, that the engorged 
vessels appear as little red points studding the surface, which 
is at once clearly seen when a lens is used, for generally the 
removal of the scales by the fingers tears open the vessels 
and they appear as little bleeding points. 

The disease may be acute or chronic, generally the latter. 
It may be hereditary. It is often general, but usually local- 
ized to several regions of the body. The chief seats of 
psoriasis are the elbows and knees and the head, but the 
body on both aspects and the limbs are frequently affected 



160 THE DETAILED DESCRIPTION 

also. It attacks persons of all ages, but there is this re- 
markable distinction to be observed, that whereas as the rule 
in the young it is associated with nutritive weakness and 
even the lymphatic temperament, in the elderly it often oc- 
curs in those of gouty diathesis, and hence assumes a more 
inflammatory aspect. There are exceptions in the case of 
the young who inherit a gouty constitution. All conditions 
of debility favor the occurrence of psoriasis, especially about 
the time of puberty. But many persons attacked are appa- 
rently healthy and strong. 

A number of varieties of psoriasis have been made, but 
they are mostly only different degrees of intensity of the 
same essential condition — stages, not varieties — and several 
of these stages may be present in one and the same person. 
The disease begins by the development of small reddish or 
scaly points or spots, scattered here and there over a region, 
or the surface. This is termed psoriasis punctata. These 
spots gradually enlarge and then look like drops of mortar, 
hence the term P. guttata. Soon the places acquire the 
size of a sixpence or a shilling. They are mostly round, 
and being like pieces of money, the stage is termed P. num- 
mularis. These conditions may coexist in varying propor- 
tions. In some cases large patches are formed by the 
coalescence of the smaller or the continuous enlargement of 
original spots, so that a great extent of surface is covered, 
but at the same time smaller spots of the guttate or punctate 
character are perhaps present. This well-developed aspect 
is called P. vulgaris. Should patches take on a serpentine 
form the term P. gyrata is used, and if the affection is very 
chronic P. inveterata. Lastly, if the crusting is freer than 
usual and assumes a conical shape, the name P. rupioides is 
applied, the epithelial elements being in this case mixed 
with pus. This latter condition is dependent on a strumous 
habit. An important local phase is P. palmaris, likely to 
be confounded with syphilitic disease ; but the former is com- 



OF CUTANEOUS DISEASES. 161 

monly a part of a more general affection, and it does not 
begin nor is it limited to the palm of the hand, as is the 
syphilitic disease as the rule. 

Diagnosis This is readily made in the great bulk of 

cases ; the silvery heaped-up scales, seated upon a hyper- 
asmic cutis, which readily bleeds on their removal, and the 
special affection of the elbows and knee-joints are very cha- 
racteristic of the disease. These features, together with the 
absence of any history of a " weeping stage," distinguish it 
from eczema, which in its squamous stage only resembles 
psoriasis. Seborrhoea of the scalp simulates psoriasis, but it 
is made up of soft, easily removable fatty plates. Squamous 
syphilitic eruption of the skin is distinguished from psoriasis 
by the presence of concomitant evidences of syphilis else- 
where, by the fine, few, adherent scales on the patches, 
which lack the silvery scales of simple psoriasis, by the ab- 
sence of the disease from the elbows and knees, and the 
presence of an infiltrated cutis beneath the scales which 
does not show the bleeding points on removal of the scales, 
as in simple psoriasis, etc. 

Treatment The treatment of psoriasis, if given in proper 

detail, would occupy considerable space. We can only indi- 
cate the main points of the matter here. In acute cases in 
young people, if the skin be hypera^mic, in the early stage 
diuretics, in our opinion, are very valuable, together with 
alkaline baths daily, or every other night, with free inunc- 
tion of oil afterwards. The same line of procedure applies 
to acute psoriasis, or to psoriasis of an inflammatory charac- 
ter in a chronic state in the adult ; but it is important to deal 
under these circumstances, with any gouty tendency or any 
loaded state of system due to torpid excretion which maybe 
present, and those " modifying influences" so commonly in 
operation, and which are mentioned under the head of gene- 
ral principles of therapeutics, at the end of Part I. of this 
book, should be carefully sought put and dealt with. We 

14* 



162 THE DETAILED DESCRIPTION 

may say by way of summary on this point, that whenever 
psoriasis is acute or hyperaemic, the action of the bowels and 
kidneys should be for the time augmented with the view of 
diminishing such hyperemia. 

But in ordinary indolent, typical, or chronic conditions 
tonics are needed, and certain local applications for the re- 
moval of scales and for checking of the hyperplasic growth 
of the cuticular cells. As regards tonics it may be said that 
children do best on cod-liver oil, quinine, and iron, though 
arsenic is indicated if the scales be very plentiful and silvery 
(see formulae 90, 92, 106, 107), which must, however, be 
properly proportioned in dose to the age of the patient. 
Locally alkaline baths may be used with the inunction of 
oil as long as hyperemia is decided ; subsequently mild tar 
applications as (70), or an ointment composed of five grains 
of white precipitate and a like quantity of nitric oxide of 
mercury, carefully levigated and mixed up with an ounce of 
lard and a little scent, may be firmly rubbed into the spots 
night and morning. In adults the general condition of 
health must be carefully estimated and dealt with accord- 
ingly ; but yet, in the weakest as well as in the strongest, the 
necessity of a due performance of the functions of excretion, 
the prescription of appropriate tonics, and the regulation 
of the diet in view of a gouty tendency, a scrofulous dia- 
thesis, under-feeding, over-nursing, and the like, are to be 
scrupulously observed. We think arsenic advisable, if at 
all, in indolent cases, with free, well-marked, silvery scali- 
ness (see formulas 90 et seq., and 106 et seg.). In anaemic 
women, iron is of essential importance. In the leuco-phleg- 
matic, and in women with leucorrhoea, the mineral acids, 
ix*on, and bitters, with cod-liver oil, have done us best ser- 
vice. Phosphorus sometimes does good. 

Locally, the first step is to remove the scales of psoriasis. 
Tepid baths act efficiently in this respect in a large number 
of cases. They may be used every, or every other, night, and 



OF CUTANEOUS DISEASES. 163 

give great comfort. Two ounces of bicarbonate of soda or 
borax may be added to help the loosening of the scales from 
the surface. With baths it is usual to employ some tarry 
preparation. Several formulae containing tar are numbered 
68, 69, 70, and 71. They should be applied cautiously to a 
small region at the outset, for, often where they a priori 
might be thought to agree, they do positive harm. When 
borne well they should be, as Duhring most justly points 
out, " used in small quantities and effectually worked into 
the skin." Hebra's favorite preparation is a mixture of 
equal parts of liquid pitch, alcohol, and sapo viridis, but it 
is often too irritating for English skins, except in the case 
of very indolent patches. Other good remedies are mercu- 
rial preparations, the citrine ointment diluted with one or 
several parts of lard or vaseline. The one of most general 
use is composed of five grains of white and five of red " pre- 
cipitate," and an ounce of lard. It is very efficacious in 
psoriasis of the scalp. To obstinate patches of limited ex- 
tent we often apply the strong mercurial (" blue") ointment, 
diluted with six times its quantity of lard. 

Lastly, we must mention the use of crysophanic acid in 
psoriasis, in the proportion of from ten to forty grains to an 
ounce of lard. This ointment often rapidly removes psoria- 
sis for a time, but in many cases the disease soon returns, 
and the remedy has its drawbacks in that it stains some 
people's skin a mahogany color, or excites so much irritation 
that patients get frightened and change their doctor. The 
remedy may be used in moderate strength to a few patches, 
and then the area of its application and the strength of the 
preparation may be gradually increased, but a few rubbings 
for a minute or two into a given spot or patch soon removes 
the disease, which is replaced by a whitish surface, the cir- 
cumference being stained dark brown. We have always 
employed the remedy with considerable caution because of 
the annoyance caused to some patients. 



164 THE DETAILED DESCRIPTION 

Purpura is characterized by extravasation of blood into 
the cutis and sometimes internal parts of the body, and is 
usually attended by constitutional disturbance. The term 
does not include the extravasation due to mechanical causes, 
nor the occasional secondary occurrence of hemorrhage in 
lesions of the skin, such as Herpes, Pemphigus, Urticaria, 
etc., which especially occur in old and debilitated persons, 
though such names as Purpura urticans, Purpura hydroa, 
etc., have been applied, nor the hemorrhagic eruptions or 
purpuric conditions associated with malignant forms of the 
acute specific diseases and with scurvy. The spots of pri- 
mary purpura are at first of a deep red or scarlet color, and 
as they fade away they exhibit the usual changes presented 
during the absorption of blood in the skin. Three forms of 
purpura are usually described. 

In Purpura simplex the extravasations are of infinite 
variety, though attaining a large size. The eruption is sym- 
metrically arranged, general, though especially developed on 
the legs, it is often sudden, and usually unattended by con- 
stitutional disturbance, though debility is present. In Pur- 
pura hemorrhagica the conditions are altogether of greater 
gravity both as regards the number, of extent of the patches, 
of effusion, and the serious state of the patient ; hemor- 
rhages from the mucous surfaces being common. These 
purpuric conditions must be carefully distinguished from 
scurvy, which occurs principally amongst seamen who have 
been subjected to a deprivation of fresh food, and especially 
fresh vegetables. In scurvy also there are often inflamma- 
tions and ulcerations about the legs and gums, and consider- 
able constitutional disturbance preceding the eruption. 

There is a third variety of purpura which may be dis- 
cussed here, though it has been variously considered as a 
rheumatic affection, a purpura, a scurvy, and an erythema 
nodosum. It is complicated with hemorrhages and joint af- 
fection. It is known as Peliosis rheumatica or Rheumatic 



OF CUTANEOUS DISEASES. 165 

purpura. The symptoms consist in the onset of some fever 
w:th pains in the joints, and the subsequent extravasation of 
blood in spots, after which the joint pains subside. Dr. 
Kinnicott considers the disease as distinct from erythema 
and purpura, whilst Dr. Liveing, who has also devoted espe- 
cial attention to the affection, considers it to be nothing 
more than erythema nodosum, E. tuberosum, etc., in which 
severe joint complications are known to occur, accompanied 
by an unusual degree of hemorrhage into the patches. 

Treatment. — The true forms of purpura require rest, care- 
ful dieting, and the administration of the mineral acids, 
quinine, perchloride of iron, turpentine (100), gallic acid, 
ergot, etc. Many cases, however, will be found to yield only 
with great difficulty. 

Ringworm, see Tinea. 

Rodent Cancer, or Ulcer, is in Europe generally 
not specially distinguished from epithelioma, but in England 
it has been regarded as a distinct form of cancer, though 
closely allied to epithelioma on account of its very slow 
growth, its appearance, and the non-infiltration of the lym- 
phatic glands. We have, however, recently demonstrated 
its true origin from the epithelial cells of the sheaths of the 
hairs and its essentially epitheliomatous nature. It is the least 
malignant form of cancer, and rarely begins before the age 
of fifty, though it has been met with as early as the age of 
twenty-five. It may commence in a pre-existent mole, or 
as a slightly crusted minute excoriation, probably made by 
scratching, or, more often, as a pale, solitary, indolent tuber- 
cle, with a distinct, slightly rolled, well-defined edge, some- 
where in the upper two-thirds of the face, and especially about 
the side of the nose. After two or three or several years, 
slow, and comparatively painless enlargement, the spot ulcer- 
ates in the centre, and the ulceration unequally follows the 



166 THE DETAILED DESCRIPTION 

extending edge, so that there is a characteristic dry, glossy 
ulcer bounded by hard, rolled, sinuous or gnawed-looking 
edges, which are not undermined, as in ordinary cases of 
epithelioma. There is little if any cachexia, and the lym- 
phatic glands, in relation with the seat of the ulcer, are never 
infiltrated, as in the ordinary forms of epithelioma, though 
they may be irritated and temporarily enlarged. The disease 
progresses perhaps for four, five, or more years without at- 
taining the size of a sixpence, but its progress is slowly con- 
tinuous, and eventually the ulceration extends through every 
texture, even perhaps to the brain, leaving a. wide hideous 
cavern, with precipitous sides, sharply separated from the 
healthy skin around. 

Treatment. — Cauterization may be successful in the earliest 
stages of the disease, and in certain slight cases, but, after 
an extended experience of patients with rodent ulcer, we 
are convinced that the right plan is to excise freely, and 
to cauterize the surgical wound with the actual cautery or 
by the application of chloride of zinc paste. The line of 
incision requires to be made with judgment, so that it may 
really run sufficiently wide of all disease. 

Roseola is a hyperemia of a rosy hue, either sympto- 
matic, and then part of certain acute febrile disease, as rheu- 
matism, vaccinia, cholera, etc. ; or idiopathic, as seen mostly 
in children during change of season (R. infantilis), and in 
connection with slightest stomach derangement. It may be 
general and resemble measles, but there are no true catar- 
rhal symptoms ; the rash is not crescentric in character, and 
is more rosy than that of measles. Though it may be dis- 
tributed more or less wholly over the body, still it is deci- 
dedly patchy in character. It may occur in rosy circles and 
rings (R. annulatd), especially about the limbs, and in the 
autumn or summer (R. autumnalis and R. (Estiva). 



OF CUTANEOUS DISEASES. 16T 

Treatment In the idiopathic forms salines and laxatives 

should be exhibited and some simple ointment used. 

Rupia In this eruption small flattish bulhe are devel- 
oped, with contents which are at first fairly clear, but quickly 
assume the aspect of a mixture of blood and pus. The bullae 
dry into dark thick scabs, which hide unhealthy ulceration. 
The crusts increase by additional discharge, which " dries 
on," as it were, in layers from below as the ulceration in- 
creases. These crusts are consequently conical, stratified, 
dark, and adherent, and are termed "cockle-shaped" crusts. 
They are in fact diagnostic of rupia. Should the crusts be 
moderate in size the disease is termed R. simplex ; if large 
and prominent, R. prominens ; if the ulceration is excessive 
and phagedenic, R. escharotica. The disease is always 
syphilitic. 

Treatment This should be as for the tertiary syphilis, 

see (84 et seq.). The ulcers may be cleansed by iodide of 
starch, and dressed with black wash or (61), (81), (82), or 
(83). 

Scabies or Itch is caused by the burrowing in the skin ■ 
of an insect called the acarus scabiei. This burrowing ex- 
cites much itching and some hyperaemic rash ; the patient 
scratches for relief and so occasions much of the rash that is 
seen in scabies. Hence scabies consists of an eruption due 
to the presence of acari.in their burrows : together with a 
secondary rash, the result of the irritation of the skin. The 
appearance presented by the acarus in its burrow, which is 
characteristic of scabies, is as follows : Where the acarus 
enters a vesicle forms, and the animal's* course is traced by a 
slightly raised, straight, or tortuous line (cuniculus) from one 
to many lines in length, at the end of which the presence of 
the imbedded intruder is marked generally as an opaque spot; 



168 THE DETAILED DESCRIPTION 

it may however be dark from dirt. The furrow or cuni- 
culus itself becomes discolored by dirt, and then has a dark 
tint w r ith darker dots along its course, probably, in part, the 
excreta of the acarus. Now these furrows are mostly seen 
in the adult, in the interdigits and about the wrists in the 
early stage of the disease, but subsequently about the penis 
at its upper line and more rarely other parts of the front of 
the body below the nipple level. In children the buttocks 
and feet may alone be the seat of scabies. Of course, the 
furrows lose their characteristic appearance after a good 
scratching, as they are torn open and the acarus frequently 
dislodged, a very common appearance then is a ragged line of 
torn cuticle indicative of the opened cuniculus and starting 
away from a spot, marked by indications of the shrivelled 
vesicle which formed at the place where the itch insect began 
to burrow, and observed to end sometimes in a small circu- 
lar, little depression, bounded by edges of ragged cuticle, 
from whence the acarus was dislodged by the fingers in 
scratching. If patients are cachectic both the vesicle and 
the furrow may suppurate, as in so-called pustular scabies. 
The " secondary rash" consists of hyperasmic follicles and 
papillae forming papules, of ecthymatous pustules excited by 
scratching, and sometimes of eczema, and urticaria. The 
results of irritation are seen in early scabies, in the adult on 
the front of the forearms and about the wrists ; in chronic 
scabies on the front of the belly and on the upper part in 
front and inner surface of the thighs ; in children about the 
lower limbs, buttocks, and abdomen. Scabies is accompa- 
nied by marked itching, which is always worse at night, and 
several members of a family are often the subjects of attack 
at the same time. Cuniculi are absolutely diagnostic, but if 
these cannot be detected, itching at night in persons who 
have a pimply rash in the interdigits or forearms or upper 
line of the penis is very suspicious, and much more so if 
several persons in the same family are similarly affected. 



OF CUTANEOUS DISEASES. 169 

Scabies in Private Practice — It is important to remark 
that scabies often differs very much in aspect, according as 
it occurs in hospital or in private practice. Amongst the 
poor, and especially the uncleanly, the burrowings of the 
acari in the skin are attended with the formation of papules, 
vesicles, pustules, wheals, etc., in abundance. But amongst 
the well-to-do, and particularly those who observe great 
cleanliness, the ordinary results of the irritation produced by 
the acari may be almost, if not entirely, absent. So that if a 
student were to be guided by the ordinary descriptions given 
in books of scabies, he would certainly not be able to diag- 
nose the scabies present. The disease would not correspond 
in description to papular, pustular, or vesicular scabies, and 
yet true scabies might be present. We have seen several 
cases lately in which patients complained of itching intensi- 
fied at night in different parts of the body, and in whose skin 
nothing could be detected but a few cuniculi about the hands, 
or the penis, and an apology for a vesicle here and there. 
We have seen a multitude of acarian furrows about the hands, 
and other parts, in a case of scabies, and nothing else. In 
other cases we have observed just a few very fine, delicate, 
pale, flesh-colored papules, the result of irritation set up by 
acari present in the skin, and nothing more, and these, which 
were lichenous papules, were difficult to make out. In all 
cases in which a patient complains of itching aggravated at 
night, even though there be none of the ordinary evidences 
of scabies present, yet a diligent and active search for cuni- 
culi should be made about the hands and penis. We have 
known patients treated with powerful internal remedies for 
" prurigo," lichen, and the like for weeks, whilst scabies, 
which existed, was wholly unsuspected because there were 
no papules and pustules present. Papules, pustules, and 
vesicles are indeed accidental accompaniments of scabies. 
Scabies should be .looked upon as consisting essentially of the 
acari in their furrows (cuniculi) — i. e., the real scabies, and 
15 



170 THE DETAILED DESCRIPTION 

the phenomena of irritation (papules, pustules, etc.) super- 
added, which, under certain circumstances, ma)' be entirely 
absent. 

Two or three cases of scabies limited to the penis have 
recently come under our notice. In all of the cases careful 
search detected cuniculi. In two, suppurating buboes were 
produced by the irritation, and the disease was thought to be 
syphilitic. The diagnosis was rendered easy by the absence 
of any decided induration about the scabies spots, their 
vesico-pustular origin, pruritus intensified at night, the pre- 
sence of cuniculi, and the absence of any concomitant evi- 
dence of syphilis. 

Treatment — The majority of cases are cured by a free in- 
unction night and morning of (114) or (120) for three nights 
and mornings. The patient must thoroughly wash himself, 
and if free from itching on the fourth night may be regarded 
as well. It is important not to overdo the sulphur inunction, 
but discontinue it after a day or two, for it often sets up in 
itself irritation, and the continuance or increase of itching is 
taken for an aggravation of the disease. After three days' 
treatment the remedy may be lightly applied to any solitary 
vesicles that make their appearance. If any parts feel hot 
and tender (74) should be used to soothe. In chronic scabies 
it may be necessary to make freer and more potent applica- 
tions (110 et seq.). Often the free use of storax ointment 
will be found most effectual ; and ointments of iodide of 
potassium and carbolic acid are also efficacious. 

Scleroderma is known by the names of Sclerema, 
Scleriasis or Hide-Bound disease. 

This affection is usually considered under two heads, viz., 
S. adultorum, or true Scleroderma, and what is probably a 
totally distinct affection, the so-called Sclerema neonatorum. 

Scleroderma adultorum is a rare affection, characterized 
clinically by a shining, tense, inelastic, shrunken condition 



OF CUTANEOUS DISEASES. 171 

of the skin, and extending usually over a considerable area 
of the body, and limiting the movements of the regions 
affected. In consequence of this condensation and shrink- 
ing, by which the underlying parts, over which, however, 
the skin is movable, are bound down and rendered immo- 
bile, the muscles, and even the bones may eventually waste, 
and whilst distortion may occur about certain apertures, as, 
for instance, those on the face, the parts about them being 
dragged out of normal position as by an extensive cicatrix. 
The aspect presented is very striking, and has been likened 
to a petrified, or frozen limb, or a corpse. When the change 
extends over nearly the whole body the patient becomes a 
helpless cripple, and the functions of deglutition and respira- 
tion may even be interfered with. The disease is usually 
very symmetrical, and may begin in one or more parts of the 
body ; the change is usually very extensive, and the dis- 
eased skin has an ill-defined border, with or without a 
velvet fringe, and passes insensibly into the healthy skin. 
Moreover, although the skin is dense and hard, it never ap- 
pears thickened, or as if infiltrated with a new deposit in the 
exact form seen in Morphcea, but thin and shrunken. It is 
necessary to pay attention specially to these points, because 
they are insisted on by such observers as Bulkley and Yan 
Harlingen, who deny that Morphcea is a circumscribed form 
of this affection (vide Morphcea), as held by Fagge, Tilbury 
Fox, Hutchinson, and Liveing, in England, and by Kaposi. 
Scleroderma commences more commonly at the back of 
the neck, and thence spreads to the face and trunk and even 
the limbs, or it may begin in the limbs and especially the 
hands and arms. It is far more common in females, and, 
though occurring at any age, from childhood upwards, is 
generally met wiih in adult or middle life. The affected 
parts usually feel cold, and are lower in temperature, and 
where the condensation is greatest the functions of the 
sudoriparous and sebaceous glands, of hair formation, and of 



172 THE DETAILED DESCRIPTION 

the nerves of sensation, are interfered with, just as in Mor- 
phoea. So, too, irregularities of pigmentation occur fre- 
quently, and white patches may form, or more or less densely 
pigmented ones. The general health is often apparently good, 
and the patient may cease work simply from the increasing 
difficulty of motion in the parts ; or the health may be mani- 
festly bad, especially from rheumatism or heart disease, and 
there is frequently considerable anaemia. Apart from these 
influences, there is very little history of direct causation to be 
obtained, except, perhaps, a chill, exposure, or the sudden 
cessation of the menses. The onset may be pretty acute, 
but is nearly always very chronic. There is no febrile move- 
ment ushering in the disease, and no evidence of any inflam- 
matory action, but there may be some burning and stinging 
pains, and disturbances of pigmentation. As secondary 
effects, the constringing skin may cause some oedema 1 and 
even perhaps gangrene of the tips of the fingers and toes ; and 
further, the prominent knuckles, etc., may also become ill- 
nourished and ulcerated. In some of the records it is stated 
that the general health throughout was unaffected, but in the 
cases we have met with the general debility was great, and 
the functions of the stomach, etc., were much impaired. 
Indeed, Dr. John Harley regards the skin changes as a part 
only of a general affection of the sympathetic system of 
nerves. The course of the affection is very chronic, but it 
tends to get well after some years. Some cases end fatally, 
but usually from intercurrent disease, such as pneumonia, 
heart disease, phthisis, and Bright's disease. 

Pathology A good many microscopical examinations 

have been made of sclerodermatous tissues, from which it ap- 
pears that the epidermis is unaffected, but the cutis vera has 
its white fibrous and elastic tissues much increased in amount, 

1 Some observers have described also a primary cedematous or 
brawny condition. 



OF CUTANEOUS DISEASES. 173 

or at any rate the bundles are very densely packed in the 
corium. The fat cells become atrophied, and, in the subcu- 
taneous tissue, the fibrous elements become increased, and 
in well-marked regions of the disease the whole becomes 
welded into one dense felt. Kaposi 1 found the bloodvessels 
diminished in calibre, but here and there the perivascular 
sheaths distended with lymph corpuscles. He considers the 
disease as due to a generally abnormal state of the nutritive 
processes, which induces thickening and stagnation of the 
lymph, and consequent firm rigid infiltration of the cutis, 
and the subsequent overgrowth and shrinking of the con- 
nective tissue. 

Differential Diagnosis There are few conditions that 

could possibly be mistaken for Scleroderma by those who 
have seen the disease, but it is necessary where oedema exists 
to distinguish it from conditions induced by the latter, and 
from the brawny induration of diffused cancer and elephan- 
tiasis arabum. In the very young especial care must be 
used to discriminate it from the so-called Sclerema neona- 
torum. 

Treatment — We have always carried out the administra- 
tion of cod-liver oil, iron, mineral acids, phosphoric acid, 
nux vomica, and plenty of light nourishing diet, but it can- 
not be said that the immediate influence of this is very per- 
ceptible. Partial good effects have been obtained from 
electricity. 

Scrofuloderma — This disease must be carefully dis- 
tinguished from lupus, though there may be some difficulty 
w r hen the latter occurs in a scrofulous subject. It commences 
as indolent, painless, livid tubercles that very slowly soften 
up and give place to foul, ragged, unhealthy ulcers with pallid 
granulations, free secretion, and often much crusting. Occa- 

1 Syd. Soc. Trans., p. 123. 
15* 



H4 THE DETAILED DESCRIPTION 

sionally the ulceration is very superficial, and creeps along 
the surface. This is the form which usually results from the 
slow breaking down of chronically inflamed and strumous 
glands. Marked scrofulous features will be recognized in 
this disease in the family history, the physiognomy, the 
chronic glandular inflammation, the strumous affection of the 
eyes or ears, and the possible coincident disease of the spine 
or joints. 

Treatment Internally, this consists in endeavoring to 

counteract the strumous habit by giving cod-liver oil or some 
equivalent, the iodide or phosphate of iron, quinine, or the 
sulphide or chloride of calcium, and good food in variety. 
Locally, the sores must be cleansed by such applications as 
iodoform or the iodide of starch paste, and the pus produc- 
tion may require checking by a mild mercurial ointment. 
Later, the sore may require a more stimulating ointment or 
plaster, of which the mercurial preparations are the more 
suitable. 

Seborrhcea This consists in an excessive secretion of 

sebum. The disease attacks the scalp and the face chiefly, 
but may occur on other parts of the body. It is usually lo- 
calized to one region, such as the scalp or the nose, but not 
necessarily. In the newly born it may be pretty general, 
forming a fatty layer over the surface, a modification or rem- 
nant of which is seen in the caked incrustation that forms on 
the scalp of young infants. Seborrhoea may be slight and 
temporary, or obstinate and chronic. Patients affected by 
it are generally of lymphatic temperament and weak. Se- 
borrhoea is not usually accompanied by any local symptoms, 
except those due immediately to the presence or excess of 
sebum, but there may be decided heat, hyperemia, and swell- 
ing as about the nose and cheeks. There is always itching. 
The actual sebaceous secretion varies in aspect. It may be 
more or less soft, so that the skin of the affected part is oily ; 



OF CUTANEOUS DISEASES. 115 

this is termed S. oleosa; or it may dry into fatty plates, 
consisting of dirty white flat scales that feel greasy, and are 
easily detached, exposing a very slightly reddened and non- 
excoriated skin, in which the sebaceous glands are more dis- 
tinct than usual. This is the common form of seborrhoea. It 
is termed S. sicca, and constitutes what is termed "dandriff " 
or "scurf" in the head, Thirdly, the fatty secretion may 
take the form of little plugs distending the orifices of the 
glands, and then the skin feels harsh like a file ($. cornea). 
The seats of seborrhoea are especially the scalp and the face. 
It is liable to be confounded with eczema, but in seborrhoea, 
although the skin is reddened, there is no breach of surface 
as is seen when the scaliness and crusting are removed. The 
follicles are seen also to be more patent than usual, and the 
incrustation is also soft and greasy, and not the result of the 
drying of " discharge." 

Treatment It is requisite to give tonics and arsenic, as 

(90), (93), (94), (103): locally to get off 1 the crusts by oily 
inunction, and to apply astringents, as (14), (25), (40), (51), 
(00), (73). 

Strophulus or Red Gum This term has been ap- 
plied to many different eruptions, consisting of soft red 
papules in infants ; in one case, to hyperagmic papillae, in 
another, to hypercemic sweat glands, and again, to distended 
sebaceous glands. So-called strophulus, characterized by 
bright-red points, seated on the face and arms of children, 
is, in fact, a hypera?mia of the papilla? or sweat glands, mostly 
induced by the child being kept very much wrapped up, and 
so overheated. S. albidus is the term given to the small 
pearly-white specks seen about the face of children, and due 
to distended sebaceous glands. The hyperremic states alluded 
to above are exaggerated by any stomach disturbance. 

Strophulus pruriginous is a modification of Lichen 
urticatus. When, in ill-nourished children, that disease be- 



176 THE DETAILED DESCRIPTION 

comes very chronic, the "wheal" or "urticarial" aspect 
may give place to the " pruriginous" almost, if not entirely, 
and when the skin is covered pretty uniformly w r ith the pru- 
riginous papules only, then the condition known as Stro- 
phulus pruriginosus is present. At least this is the history of 
cases I have seen, though I notice Duhring states that Hardy 
recognized a case of true prurigo as one of S. pruriginosus. 
Treatment. — Some mild aperient and antacid should be 
given, with the adoption of a cool regimen, and the local use 
of some simple soothing lotion, as (74). S. pruriginosus 
needs locally simple baths, followed by inunction of oil, gen- 
erous diet, and cod-liver oil and iron internally. 

Sudamina are the tiny, rounded, non -inflammatory vesi- 
cles formed by the collection of sweat between the layers of 
the cuticle, and due to the excessive or suddenly augmented 
secretion of sweat. They are especially met with in the 
summer months, when the sweat glands are very active, and 
more particularly in the course of a febrile disease, such as 
phthisis or acute rheumatism, and during the critical sweats. 
The causes that lead to the formation of Sudamina may also 
excite some inflammation, and then the usually transparent 
contents of the sudamina may become opaque and puriform, 
and the vesicles may be complicated by miliaria. Sudamina 
seldom exceed a pin's head or millet seed in size, though, 
very rarely, they become confluent into bullae. The vesicles 
may crowd the surface or be sparsely distributed, and they 
are most often seen about the neck and trunk. 

Treatment — As with miliaria, when met with as an acci- 
dental occurrence in the pyrexial state, the presence of su- 
damina is of little importance, but otherwise it should be 
borne in mind that they may be evidence of debilitated 
health which requires tonics. 

Sycosis is the name given to inflammation of the hair 
follicles of the beard and whiskers. There are two forms. 



OF CUTANEOUS DISEASES. 17T 

In the one the disease is caused by a vegetable parasite, and 
is designated Tinea sycosis. (See that disease under the 
head of Tinea.) The other arises as an idiopathic inflam- 
mation of the follicles, and then is called simply sycosis. In 
this latter simple or non-parasitic form the disease consists 
in simple catarrhal inflammation of the follicles, character- 
ized by pain, heat, redness, and the speedy development of 
pustules, at first small, then larger, which have this pecu- 
liarity, that they are pierced by a hair and are scattered, 
here and there, about the hairy parts of the face. The pus- 
tules, which indicate that the whole hair sacs and their walls 
are inflamed, may become more or less indurated at their 
bases, forming quasi-tubercles. If the inflammation is 
severe, and the pustules are crowded together, there may be 
considerable discharge and crusting. The derma and con- 
nective tissue textures of the affected part may be involved, 
so that the parts are reddened, hot, swollen, and infiltrated, 
and the patient may suffer great pain. The disease, how- 
ever, differs very much in severity. It often occurs in the 
debilitated, the intemperate, the dyspeptic, and eczematous. 
It often, too, runs a very chronic course, especially in stru- 
mous subjects, and in such cases more or less atrophy and 
loss of hair may result ; in fact, as a consequence of the depth 
and severity of the inflammation, a condition simulating 
lupus may result. 

In some cases the upper hairy lip is the seat of the syco- 
sis, and the disease begins as a catarrh of the mucous mem- 
brane of the nose, the inflammation spreading down and 
involving the follicles of the lip. The characters in the 
main are those of sycosis, but there may be great swelling 
and infiltration, so that the disease looks like a mass of 
fleshy outgrowth, with considerable elevation. There are, 
however, usually, characteristic pustules. We presume this 
is the Impetigo sycosiformis of authors. The main thing to 



178 THE DETAILED DESCRIPTION 

recollect about the disease is the necessity for soothing 
treatment. 

Treatment — It is generally considered that epilation rap- 
idly cures the disease, but this is a mistake, and, indeed, the 
procedure often does harm. Some say that sycosis is caused 
by the premature development of a new hair in the follicle, 
and so epilation does good. This is not true. Others think 
that epilation relieves the tension. In some cases the in- 
flammation does not extend to the deeper part of the folli- 
cle, and so the procedure can scarcely be of service ; but it 
no doubt is of use if there be much chronic inflammatory 
thickening involving the deep parts of the follicle with free 
suppuration, especially if there be much tension, and the pus 
has a difficulty in escaping. Sycosis should really be treated 
as a simple inflammation, locally by hot fomentations and 
soothing remedies in the early and acute stages, and subse- 
quently by the use of astringents, as (75), followed by weak 
mercurial ointments, and, lastly, tar or sulphur applications. 
Internal treatment consists in the use of aperient tonics, as 
(95), or saline aperients at the outset, in cases where there 
is much hyperemia and patients are gouty ; later on cod- 
liver oil and iron are needed, and lastly, a course of Dono- 
van's solution where there is much indolent thickening. 
Where there is. much thickening, painting with liquor po- 
tassae, followed up with the use of mercurial plaster, is often 
of service, but the disease must be in an indolent state for 
this treatment. We always find, where there is much infil- 
tration about the follicles and any tendency to atrophy of the 
textures, that antistrumous remedies internally and mild as- 
tringents externally do most good. 

Syphilis of the Skin is met with in connection with 
hereditary and acquiied syphilis. 

Hereditary syphilis is practically nearly synonymous with 
congenital or infantile syphilis. This form is uncommon 



OF CUTANEOUS DISEASES. 179 

before the end of the second or beginning of the third week, 
and it is rare after the sixth month ; the usual period of its 
occurrence is when the child is about three weeks or a month 
old. No one can mistake the tainted infant : the general 
aspect is more or less marasmic ; the child presents a shriv- 
elled, " old man"-like aspect ; the skin is dirty and muddy, 
it has lost its elasticity, and hangs in loose folds ; it is dry, 
often exfoliating, and more or less erythematous about the 
buttocks. The cry of the child is harsh and cracked (cha- 
racteristic), and " the snuffles, produced by inflammation 
and ulceration of the nasal mucous membrane, are present." 
The disease is further characterized by the presence of 
mucous tubercles about the anus or mouth ; fissures at the 
angles of the mouth : ulceration of mucous surfaces ; a high 
arched palate ; inflammation of the thymus gland ; various 
eruptions over the body, especially about the feet and hands, 
in the form of erythemata or bullae ; a subacute onychia is 
possibly present ; and these, together with a family history 
of syphilis, are diagnostic. 

With regard, however, to the eruption, it is generally in 
the form of a dull-red erythema of the hands, feet, and peri- 
anal region, with or without tubercular formations ; but it 
may in cachectic subjects consist in ugly ulcerations arising 
out of tubercles, bullae, or pustules. 

The treatment consists in gently mercurializing the child 
by the use of gray powder or mercurial inunction (a small 
portion of blue ointment being rubbed into the soles of the 
feet each night), in keeping up the nutrition of the body by 
good food, by giving cod-liver oil and chlorate of potash, 
and, if the child is nursed, in giving the nurse a course of 
iodide of potassium [which the infant imbibes with the milk]. 

Acquired Syphilis. — When in the adult an eruption is due 
to this cause, there is usually imparted to it a coppery tint, 
and a more or less circular form ; the distribution of the 
eruption is general over the body and usually there is ab- 



180 THE DETAILED DESCRIPTION 

sence of pain and itching ; there is also a polymorphism 
about the eruption, that is, it is made up of a variety of 
forms such as papules, tubercles, and ulcers (occasioning loss 
of substance), etc. "In addition, cachexia, ulcerated throat 
or tongue, alopecia, nocturnal pains in different parts are 
the usual concomitants ; and a history of the primary disease 
may be connected by different links with the existing con- 
dition by a series of syphilitic occurrences. 

Syphilodermata may be divided for all practical purposes 
into three groups : (a) those that are simply hyperamiic ; 
(b) those that have deposit (or new tissue formation) as the 
main feature ; and (c) degenerative lesions, the result of 
suppuration and ulceration of the syphilitic new tissue formed 
in the skin. 

The following sketch may throw light on this subject. 
The first effect of the syphilitic poison upon the general sys- 
tem is to give rise to syphilitic fever and transitory hyper- 
amiic lesions, as roseola and erythema, which are phenomena 
belonging to the early stage of syphilis. These occur with 
the syphilitic fever, in patches over different parts of the 
body, and in connection with many other evidences of the 
action of the syphilitic poison — i. <?., specific sore throat, 
neuralgia, alopecia, etc., and this rash is not pruritic. Suffi- 
cient time having elapsed for the action of the poison upon 
the nutrition of the textures, a second period ensues, in 
which modifications of their- normal growth take place — 
that is, new tissue is formed (granulation or syphilitic tissue), 
and the results appear in the form of erythematous, papular, 
tubercular, squamous, and pustular eruptions, mucous tuber- 
cles, gummata, etc. The first five of these occur in the 
early stage of disease. They occur, of course, in connection 
with the general symptoms of the disease, including sore 
throat, falling off of the hair, neuralgic pains, etc. They 
affect the body generally, and are not irritable. 

The erythematous form is the earliest cutaneous manifes- 



OF CUTANEOUS DISEASES. 181 

tation. It may occur at the onset as a subcutaneous mottling 
or niaculation, similating measles or even a typhus rash, only 
the general symptoms of these diseases are quite wanting, 
but usually it appears as more or less circular spots the size 
of from split peas to shillings, of at first a rosy hue, and later 
on acquire a reddish or purplish tint. They are best seen 
about the trunk, but also on the limbs, and come out most dis- 
tinctly after exposure of the skin to the cold air or after a 
cold bath. The rash does not itch, and the medical man 
often discovers it for the patient in its early stage. It runs 
a very indolent course, but is attended by significant general 
symptoms, enlargement of the glands in neck, faucial red- 
ness, and the like. In the case of the papular form, little 
dull red or brownish papules are scattered more or less over 
the body, perhaps grouped together. These enlarge into the 
tubercular form, and either of the two may suppurate and 
produce pustular syphilis ; and so it is usual for these changes 
or different forms to be found together in the same subject, 
in fact multiformity of eruption is one of the chief charac- 
teristics of syphilodermata. The squamous form is made 
up of a multitude of small, round, dull red spots, covered 
over by a few fine, thin, and adherent scales. Large patches 
are subsequently formed by the coalescence of smaller ones, 
or the crowding together of tubercles, and the disease often 
creeps along the surface in a serpiginous manner, and ulcer- 
ation is then common. But the circulating poison also 
causes the skin glands to inflame and so produces syphilitic 
acne, or in the case of the follicles so called syphilitic lichen. 
These commence also in hyperemia of the sebaceous glands 
and follicles, but the hyperemia is not now of a transient 
character, but is followed by the formation of syphilitic tis- 
sue in and about these parts. The affection of the follicles 
and glands is not limited, but the w r hole body is affected. 
If the rash be lichenous it will be noticed that the papules 
are collected together over the body and limbs in groups or 
16 



182 THE DETAILED DESCRIPTION 

clusters, and they leave on their disappearance little pits : 
and they are not itchy. In acne the spots are generally not 
irritable, and tend to ulcerate and to be mixed up with other 
forms of eruption. In both cases concomitant evidences of 
syphilis are present. Any of the earlier papular or tuber- 
cular eruptions may take on the pustular form. The nerve- 
trunks also may become irritated by the poisoned blood, 
or the deposit about them, and herpes and pemphigus occur 
as a consequence. A common occurrence is so-called syphi- 
litic palmar psoriasis, which consists in a hard, indurated, 
cracked, scaly surface, or hard tubercles about the palm of 
the hand, and in connection with other signs of syphilis. 
Syphilitic psoriasis begins in the palm of the hand as the 
rule, and occurs in connection in a large number of cases 
with specific ulceration about the tongue and other evidences 
of syphilis, by which the diagnosis is at once made certain. 
Syphilitic ecthyma is known by the indolent character of the 
pustules, their free crusting, and their tendency to ulcerate, 
and their admixture, with many other evidences of the spe- 
cific disease. The further stage of syphilis of the skin con- 
sists in the infiltration by the syphilitic granulation tissue of 
the deeper parts, and more extensively than before of the 
superficial ones, whilst the patient's general health becomes 
cachectic. Then, in this third stage, the syphilitic tissue 
softens up, suppurates, or ulcerates ; and this latter phase is 
characterized by degenerative changes in the syphilitic de- 
posit in different parts, as is seen in ulcers, onychia, etc. 

Treatment Internally in the papular, tubercular, squa- 
mous, and pustular syphilides, mercurial treatment is called 
for, and the bicyanide pill (105) is the best form. This pill 
may be given for three or four weeks, or omitted before the 
gums begin to be affected. See also (8-4 et seq.) and (104). 
Iodide of potassium may be given at the same time in in- 
creasing doses. In the ulcerating forms, if the patient be 
well nourished and strong, there is no objection to a mercu- 



OF CUTANEOUS DISEASES. 183 

rial course ; but where cachexia is marked, and the patient's 
condition is one of evident debility, iodide of potassium, with 
cod-liver oil, or iodide of iron and good food, constitute the 
best treatment. In cachectic subjects, who are debilitated, 
restless, and irritable, opium given internally is of much ser- 
vice. In reference to iodide of potassium, it must be borne 
in mind that its use is beneficial in direct proportion to the 
duration of the disease ; hence when nodes, tubercles, caries, 
and secondary ulcers are present, or when mercury has been 
fully used or apparently failed, the dose should be gradually 
increased by three or four grains every few days, until in 
the case of old-standing and ulcerating syphilis it reaches 
thirty or forty grains. In most cases the exhibition of the 
decoction of various woods is advisable ; the compound de- 
coctions of sarza and guaiacum are the best ; they keep the 
skin and bowels acting freely, and thus very materially help 
the elimination of the poison. 

When a patient is under the influence of mercury lie should 
avoid stimulants, cold, and other sources of irritation and 
catarrh ; the indulgence in stimulants, indeed, is a source of 
infinite harm, and a common cause of aggravation of syphi- 
lis of the skin. The diet should be good and nutritious, and 
the administration of mercury should always be followed up 
by a course of mineral acids and bitters, or iron and quinine, 
etc. ; or tonics may be given simultaneously with the specific 
remedy, and with a liberal hand if the general health is bad. 

Mercurial fumigation, which acts both locally and gene- 
rally, is in great favor with some practitioners. If the skin 
eruption is extensive it may be employed twice or more a 
week. 

Locally, the erythematous forms require no special appli- 
cation, but a lotion of oxide of zinc and calamine may be 
used. Should they be obstinate and leave behind any pa- 
pules, a white precipitate ointment is preferred. The squa- 
mous and papular eruptions are relieved by calomel ointment, 



184 THE DETAILED DESCRIPTION 

bichloride lotion, and nitric oxide of mercury ointments. 
The tubercular and ulcerating forms are those which require 
special local medication : in the former, the weak nitrate, or 
nitric oxide of mercury ointments, are those more especially 
useful, and nitrate of mercury may be cautiously used to de- 
stroy obstinate indurations ; ulcers may be dressed, if pain- 
ful, with a solution of watery extract of opium, or be dusted 
over with calomel, or be stimulated with the nitric oxide of 
mercury ointment, dilute nitric acid, and borax lotions (45), 
(62), (63), or treated by the local application of mercurial 
vapor. Should ulcers be very foul and dirty-looking, iodide 
of starch (52) is a good remedy, and when cleansed the sore 
may be dressed by a weak mercurial application or astringent 
wash. Formula (3), (7), (23), (58), (59), (60), (61), (80), 
(81), (82), (83), will also be found useful. 

Tinea is the generic term given to the vegetable parasi- 
tic diseases. They are : — 

1. Tinea favosa or favus, caused by a fungus called acho- 
rion Schonleinii. 

2. Tinea tonsurans, or ordinary " ringworm" of the scalp, 
cause by the trichophyton tonsurans. 

3. Tinea kerion, which is a modification of the last, and 
is caused by the same parasite. 

4. Tinea circinata, or ordinary ringworm of the body, 
which includes Burmese ringworm, Malabar itch, Chinese 
and Tokelan ringworm, etc., and is caused by the trichophy- 
ton tonsurans also. 

5. Tinea sycosis or mentagra, or sycosis parasitica, caused 
by the microsporon mentagrophytes. 

6. Tinea versicolor, or Chloasma, or Pityriasis versicolor, 
caused by the microsporon furfur. 

7. Tinea decalvans, or area, or alopecia (one form), caused, 
it is held by some, by the microsporon Audouini, but its ex- 
istence is doubtful. 



OP CUTANEOUS DISEASES. 185 

There are two other parasitic diseases which may be men- 
tioned here — viz., Mycetoma, or the inadura foot or fungus 
foot of India, caused by the chionyphe Carteri ; and Ony- 
chomycosis, or onychia parasitica, alluded to elsewhere. 

Tinea favosa is rare in England. It attacks the young, 
and is known by the presence of dry, light, sulphur-colored, 
cup-shaped, umbilicated crusts, made up of fungus elements, 
and pierced in the centre by a hair from the underlying fol- 
licle. These crusts may run together into a confused mass 
in some cases. 

Treatment. — The point is, after getting off all the crusts 
by oil soakage, to destroy the parasite by sulphurous acid 
lotion, and then epilate bit by bit of the surface, and apply 
such parasiticides as 121, 122, 134, 136, until the microscope 
shows that the hair is free from fungus. 

Tinea tonsurans is very common in the young, but is very 
rare in the adult, and when it does occur in the adult it is 
not severe. It is sometimes epidemic in schools, spreading 
from child to child by contagion. The typical disease con- 
sists of circular patches, varying from a sixpence to a five- 
shilling piece in size or larger, having a slightly raised and 
scurfy surface, the hairs on which are dry, brittle, lustreless, 
and broken off close to the scalp. These diseased hairs are 
always present, however the configurative size or scaliness 
of any given patches or areas of disease may vary. This 
condition is caused by the fungus attacking the hairs — a fact 
easily shown by soaking a diseased hair in weak potash solu- 
tion and then examining it under the microscope, when it will 
be seen that the hair is invaded to a greater or less degree by 
the conidia of the trichophyton tonsurans. These conidia, 
when very numerous, besides crowding around the hair shaft, 
collect into parcels within, and separate the fibres of the shaft 
one from another, so that the hair is split up. These short, 
broken-off, opaque, dull hairs are, as just stated, diagnostic. 
But there are many deviations from the typical aspect of 

16* 



186 THE DETAILED DESCRIPTION 

ringworm. It may consist of a few broken-off hairs in 
groups, or of isolated diseased hairs scattered here and there, 
or little patches like pityriasis, the scales concealing a few 
diseased hairs, or of diseased hairs seated in little suppu- 
rating points — i. e., hair follicles, or in typical reddish, scaly 
patches, with diseased hairs. But in all cases, typical and 
unusual, the presence of short, broken-off, brittle, diseased 
hairs suffices for the diagnosis. In no other disease do these 
occur. Tinea tonsurans and tinea circinata are often ob- 
served in the same subject, and, in fact, they are essentially 
the same, only that one occurs on hairy, the other on non- 
hairy parts. 

Treatment. — If the fungus has not got deeply into the fol- 
licle, it can readily be destroyed : therefore the more recent 
the disease the more easily can it be cured. In very recent 
cases, two or three applications of the tincture of iodine of 
double strength, or a blistering, may almost if not quite cure : 
this should be followed by the use for awhile of some mild 
parasiticide, as (121) or (122). The hair should be cut off 
the scalp for an inch or so around and about the diseased 
patches. 

In chronic cases, if there are many patches scattered over 
the head, the whole hair should be shaved or cut off close to 
the scalp ; and, if much diseased, the whole head may be 
soaked in sulphurous acid lotion (125, one part to three or 
four of water) for a week, to get rid of the disease on the 
mere surface. Then it is Avell to epilate over a certain area 
day by day, subsequently applying (136) cautiously for seven 
or eight or more applications at intervals of three or four 
days. The application will form a cake, and this should be 
removed by grease or soap in a day or two, or when it begins 
to " flake off," and before a fresh application is made. Blis- 
tering may be used instead. In getting off the caking, a 
number of diseased hairs come away entangled in the flakes, 
and this may serve in place of a repetition of epilation. 



OF CUTANEOUS DISEASES. 187 

It is no use applying (136) to the surface whilst the cake 
is on it, but a clean surface must be obtained about three 
days or so after an application. It is advisable to continue 
the applications until the hair begins to grow out in a natural 
direction and manner, and then to apply some mild parasiti- 
cide, as (128) or (134). In severe cases, epilation must be 
carried out again and again over the patches, and parasiti- 
cides must not be discontinued as long as a single broken-off 
hair can be detected, or any little dark stubs are visible, or 
until the hair grows evenly and well over the surface. The 
parasiticides that are used are very multitudinous ; a few 
suggestions will be found in the Cutaneous Pharmacopoeia. 
I have lately used an ointment made of white precipitate 
ointment half an ounce, a like amount of lard, and from 
three to six grains of the crystals of terchloride of antimony, 
and to small obstinate patches I have smeared lightly on a 
little of the terchloride of antimony, pure. It gives pain, 
but it suppurates the hairs out. It should be used with great 
caution, and to a very small spot at a time, and only by the 
medical man himself, for Goa powder is too inconvenient to 
use to private patients. 

Tinea circinata, or ringworm of the body, is character- 
ized by the occurrence of patches which are red, scaly, and 
itchy, circular in form, and with a well-defined edge. It 
begins as a little red scurfy spot, which gradually enlarges, 
and when it has reached a fair size the skin in the central 
part may be apparently healthy : usually the edge looks red 
and scaly, the centre generally somewhat paler and less 
scaly, though covered Avith a branny desquamation. The 
edge of the patch may be vesicular, and the disease is evi- 
dently inflammatory. It is excited by a fungus that spreads 
equally in all directions, and so produces the circular form. 
The inflammation falls short of that which occurs in eczema. 
Any scurfy, red, itchy patch then on the surface of the body 
should always be examined for fungus elements. The fungus 



188 THE DETAILED DESCRIPTION 

is the same that occasions tinea tonsurans, and the two dis- 
eases often occur together. 

In hot climates especially, the fungus sometimes luxuriates 
upon the skin, particularly in the mycelial form, and hence 
tinea circinata occurs in very large patches. These are very 
hyperasmic or papular at their edges, which are well defined, 
their centres desquamating and being slightly scaly. In the 
fork of the thigh and contiguous parts, patches that have the 
characters of tinea circinata in this exaggerated form mostly 
occur, and are characterized particularly by the festooning 
downwards over the thigh of a red scaly, itchy patch, that 
has a well-defined circular and papular edge. This is the 
Burmese or Chinese ringworm. 

Treatment This is always successful. The constant use 

of some such parasiticide as (122), (128), or simple tincture 
of iodine, or an ointment made of five grains of white pre- 
cipitate and ten to twenty of carbolic acid, or an application 
or two of Goa powder in severe cases, will always cure the 
disease. 

Tinea sycosis — This disease, which is very rare in Eng- 
land, unlike non-parasitic sycosis {see Sycosis), consists of 
little raised, bumpy, scurfy patches, often unsymmetrical, but 
the hairs of which are loosened, rendered brittle, and, in 
fact, changed as in tinea tonsurans. The disease is to be 
treated in a similar manner. Happily the hairs can be 
readily extracted, so that the cure is rapid. 

Tinea versicolor (Pityriasis versicolor or Chloasma) 

This disease consists of fawn-colored patches occurring in 
the parts covered by flannel, especially the front of the chest 
and the root of the neck. The patches vary in size, and 
may dot over the surface or run together so as to cover uni- 
formly a large area. They are raised and itchy, and scales 
can be scraped from them, which under the microscope are 
seen to be invaded by conidia (in heaps) and the mycelial 
threads (very wavy) of the fungus — the microspor on furfur. 



OF CUTANEOUS DISEASES. 189 

The disease is sometimes mistaken for syphilitic macuhe, but 
the latter are not raised, not itchy, and not scurfy. 

Treatment Apply (127) regularly and for about ten 

days or so after all appearance of the disease has vanished. 

Tinea herion is simply tinea tonsurans in which the hair 
follicles are a good deal inflamed and pour out an albuminous 
fluid. The special features of the disease are — the general 
prominence of the patch ; its perforation with foramina — i. e., 
the swollen mouths of the hair follicles ; the outpouring of 
a mucous fluid ; the non-suppuration of the swelling, which, 
although feeling boggy and as about to suppurate, should 
never be opened ; and the looseness of the hairs. The dis- 
ease leaves temporary bald patches behind, and the fungus 
is observed to have invaded the hairs, as in tinea tonsurans. 

Treatment Allay the inflammation by the use of an 

ointment containing a drachm of liquor plumbi in an ounce 
of lard, night and morning ; epilate ; and then use some 
very mild parasiticide, if need be, as in ordinary ringworm, 
but usually the hairs are loosened by the suppuration, and 
readily come away, whereupon the fungus dies and there is 
no need for any parasiticide, and especially as the parts being 
so tender require some simple soothing unguent, and the in- 
flamed parts heal rapidly under such a remedy. 

Tinea decalvans, see Alopecia. 

Triehorexia Nodosum or Triehoelasis In cer- 
tain states of ill health, though the patient may appear 
vigorous, the hairs become imperfectly nourished, their com- 
ponent cells are dry and not completely organized into fibres, 
and the hair consequently becomes brittle, and its structure 
disorganized. The result is the production of little knots 
here and there along the shaft, which look like nits, and feel 
hard in some cases, the hair nearly breaking at these spots. 
The hairs of the beard are usually affected, but those of the 
axilla and even head may be attacked. Under the micro- 



190 THE DETAILED DESCRIPTION 

scope the appearances presented are those of slight swelling 
of the pith, with deficiency of pigment in the central parts, 
and slight increase of the cellular elements of the shaft 
in an early stage, but generally those occasioned by the split- 
ting of and fracture of the fibres of the shaft, so that the 
aspect is similar to that produced by thrusting one besom or 
brush into another, so that the bristles or hairs interlock. 
At other times the free end of the hair is like a brush, from 
the fact of the shaft having been broken away at one of the 
nodules. The disease is not parasitic. The treatment con- 
sists in restoring the tone of the system, in anointing the 
hairs with grease, or if that fail in shaving off the hairs of 
the affected part several times. 

Urticaria, or Nettlerash. — The features that attract 
attention, and which are quite diagnostic of this affection 
are — -first, the sudden way in which the erythematous rash 
appears and disappears, or, in other words, the capricious- 
ness of the eruption ; secondly, the development of " wheals," 
like those caused by the stings of nettles, in the centre of the 
red hypersemic patches, attended by tingling and stinging. 
These " wheals" have been fully described in speaking of 
" elementary lesions." Urticaria presents differences in the 
adult and child. 

In the adult the wheals are always well marked, and leave 
no trace of their presence behind when they disappear. The 
urticaria may be acute, and is then generally the result of 
some dietetic error — e. g., the eating of shell-fish or some 
unwholesome irritating food, as potted meats, and it is at- 
tended by pyrexia often severe, with even vomiting and 
prostration ; the skin itches severely, and then out comes the 
wheal eruption. Sometimes the face is attacked and swells 
enormously, but the eruption at once discloses the nature of 
the case. Usually in the adult, however, the urticaria is 
chronic, and it is made up of recurrent crops of wheals which 



OP CUTANEOUS DISEASES. 191 

occur at uncertain times and intervals, and localities, lasting 
sometimes for months and years, and under a variety of dif- 
ferent influences, such as mental worry, exposure to cold, 
stomach derangement, physical fatigue, excesses in diet of 
various kinds, rheumatic attacks, and menstrual disorders. 
The wheal may be the seat of hemorrhagic effusion, hence 
the term purpura urticans. 

In the child the wheals may be like those seen in the adult 
in exceptional cases, and the disease is generally then of the 
acute form, but as the rule the wheals are very small and not 
so distinct, and are followed by the development of little 
fleshy papules — hence the term lichen urticatus or urticaria 
papulosa. In this malady the trunk, arms, and limbs be- 
come the seat of nascent wheals, like " bug bites," so the 
nurses say, and the lichenous condition is left behind. In 
some cases the papules may vesicate, and even tend to sup- 
purate. This lichen urticatus causes great irritation, is very 
common in the young, and simulates scabies, but it lacks the 
characteristic localization and cuniculi of the latter. The 
papules become " pruriginous" in proportion as the disease is 
chronic. 

In both children and adults the disease may be primary 
and idiopathic, or secondary to some other disease, as scabies 
and phthiriasis. In the latter, too, there will be a history 
of antecedent disease of the kind mentioned, and the actual 
concomitants of the symptoms of these diseases. In the 
idiopathic form the hyperemia and wheals exist as the sole 
disease present. 

Urticaria pigmentosa is a designation recently applied 
to the eruption we have termed Xanthelasmoidea (which 
see), because of the tendency to the formation of wheals, but 
the presence of these wheals is not the important considera- 
tion in regard to the disease, and to speak of it as an urti- 
caria is a clinical error of some moment. 

Treatment. — In the adult in the acute form an emetic may 



192 THE DETAILED DESCRIPTION 

be given if need be, with alkalies and a slight aperient. 
Chronic urticaria in the adult is much more troublesome. 
There is no pyrexia, but constant recurrence of redness and 
wheals with heat and itching. Assuming the existence of 
an irritable state of skin, the eruption appears frequently to 
be kept up by nervous debility, by dyspepsia, and by uterine 
or liver disorder. These are the common excitants of the 
disease. In loaded states of the system, large doses of alka- 
lies internally, followed by (95), and, if desirable, arsenic, 
with bran and alkaline baths (la and lb), or vapor baths if 
the skin does not act properly, are beneficial. Such lotions 
as (18), (23), (26), (27), (30), (31), (33), and many like 
ones, may be used. But the best of all, we think, is one 
made of 2 scruples of benzoic acid, to 6 ounces of water, and 
a drachm of eau de Cologne. It can be applied whenever 
the wheals trouble. A similar line of treatment must be 
adopted for the child in the early stages, though care should 
be taken to keep the kidneys acting well to see that there is 
no dyspepsia, intestinal derangement, and no improper feed- 
ing, and to give cod-liver oil if the health is poor. Locally, 
soothing remedies are needed (74) ; but sulphuret of potas- 
sium baths in chronic cases are very efficacious. Ointments 
of storax or calomel and belladonna will be found successful 
in allaying accompanying pruritis, especially if excited by 
animal parasites, such as bugs, fleas, lice, etc. There are a 
number of cases of urticaria in the adult, and lichen urticatus 
in the child, which get well with simple baths, and cod-liver 
oil and bitter tonics. These are such cases as are apparently 
unconnected with any gastric, intestinal or similar disorder, 
but seem to be associated purely with an excitable nervous 
system. 

Vitiligo is a term used by many at the present day as 
synonymous with Leucoderma, but Dr. Tilbury Fox has seen 
such a disease as Bateman describes under this term, and 



OP CUTANEOUS DISEASES. 193 

believes it to be an atrophous condition in scattered spots, of 
very rare occurrence, and differing from what Willan in- 
tended by, and figured in, his plate 60 under that name. 
Willan's plate probably represents the disease named Xan- 
thelasmoidea by Dr. Tilbury Fox (see Clin. Soc. Trans.), 
and subsequently urticaria pigmentosa by others. (See Xan- 
thelasmoidea.) 

Vitiligoidea This is a term applied to Xanthelasma, 

which see. 

Xanthelasma. 1 — Xanthelasma has received many dif- 
ferent names. For instance, Plaques jaundtres des paupi- 
eres (figured by Rayer, 1835) ; Vitiligoidea (Addison and 
Gull, 1851) ; Xanthelasma (Erasmus Wilson) ; Xanthoma 
(Frank Smith) ; Molluscum lipomatodes (Virchow, 1871) ; 
Molluscum cholesterique (Bazin). This disease occurs in 
two forms. The simple form, known as Xanthelasma palpe- 
brarum, was first figured by Rayer in 1835. It is a fairly 
frequent affection which occurs in people generally past mid- 
dle life, and has not been met with under puberty. The 
appearances presented by the yellow, slightly raised, firm, 
chamois-leather looking patches are very characteristic and 
striking, and the localization on the eyelids not less so. The 
patches begin almost invariably in the inner canthus of the 
upper eyelid, and usually the left first, thence spread to the 
corresponding part on the other side, and subsequently may 
gradually affect the lower lids and so encircle the eye. It 
is noticeable, in contradistinction to the other form, that 
those affected with this simple kind have rarely suffered 
from jaundice previously or at the time of the appearance 

1 The reader is referred for fuller information, and the literature 
of the subject, to an elaborate monograph by Dr. Pye Smith, in the 
Gruy's Hospital Reports, vol. xxii., for 1877. 
17 



194 THE DETAILED DESCRIPTION 

of the patches ; indeed, their development is unattended by any- 
general or local symptoms, and no treatment is required. 
Mr. Hutchinson called attention to its frequent association 
with a predisposition to sick headaches, but Dr. Pye Smith 
has shown that the connection is probably only accidental. 
Dr. Church recorded a remarkable instance of heredity of 
the affection, and this observation has been confirmed by 
Dr. Wilks and others. 

The multiple form, of which only about 18 * undoubted 
cases have been recorded, was first described by Addison 
and Gull, in 1851. Of the cases collected by Pye Smith 
the ages varied from 28 to 58, a younger average than in 
the other variety ; and Bazin has recorded a very marked 
case in a boy at the age of 16. This general form has in- 
variably been preceded by long-continued, often recurrent, 
jaundice, arising from an organic cause — the shortest dura- 
tion of the jaundice being six months (death from cancer), 
and the longest about six years. " The eight cases which 
proved fatal have been ascertained to be, two of cirrhosis 
with hypertrophy, one of simple, and one of cancerous, stric- 
ture of the common duct, one of obstruction from hydatids, 
two of occlusion by gall-stones, and one of ' chronic atrophy 
of the liver.' In two other cases gall-stones were passed 
during life, and in three others the symptoms were pretty 
certainly referable to ordinary cirrhosis." 

The characteristic maculae appear first around the eyelids 
precisely as in the simple form, and next usually affects the 
natural creases and folds of the skin of the palms, and then 
those of the face, neck, ears, scrotum, the soles of the feet, 

1 Pye Smith has collected 18, but he has omitted Bazin's case. 
The authors have seen another well-marked case in a London hos- 
pital, in a woman the subject of long-continued jaundice, and they 
have known of another case. Hebra and Kaposi have also recorded 
one or two cases, but of so exceptional a nature that we have ex- 
cluded them. 



OP CUTANEOUS DISEASES. 195 

the flexures of the joints, the abdomen, and the back. If 
the cause be longer continued, in addition to lines and 
patches, papules, which become confluent in nodules, have 
appeared in a few cases, beginning on the extensor aspect 
of the elbows and knuckles, but these nodules never exist 
without the maculae. The latter have also been found in 
the mucous membrane of mouth, lips, tongue, palate, trachea, 
bile-ducts, etc. The progress of the affection is very slow, 
and in very long standing cases some of the maculae and no- 
dules may grow less and even disappear. 

It is unsafe as yet to pronounce with certainty as to the 
cause, but the changes in the skin are probably due to the 
irritation produced by the circulation of bile pigment, or, at 
any rate, some improper liver product. But the reader must 
weigh such facts as that multitudes of jaundiced cases occur 
without a sign of this affection, and that simple xanthelasma 
palpebrarum is rarely associated with jaundice. 

The minute anatomy of the two forms may be considered 
together, and has been elaborately worked out by Pavy and 
Moxon, Frank Smith, Waldeyer, Hawse, Legg, Kaposi, 
Fogge, and Pye Smith. Hebra, at first, affirmed the seba- 
ceous nature of the disease, but this has been thoroughly dis- 
proved by succeeding observers. Dr. Pye Smith sums up 
the results arrived at thus : " Xanthelasma consists anatom- 
ically in a chronic hyperplasia of the deeper layer of the cutis, 
in which the papillae and epidermis, on the one hand, and the 
subcutaneous connective tissue, on the other, are only secon- 
darily involved. The process may run in two directions. 
When it follows what may be called the inflammatory type, 
the minute, round, inflammation-cells or young leucocytes 
never form true tissue elements ; molecular fatty degenera- 
tion rapidly overtakes them, and leads to their ultimate dis- 
appearance in a detritus of oil-drops, calcareous masses, and 

cholesterine crystals The other course, the disease 

may take, approaches the process of formation of a true tumor 



196 THE DETAILED DESCRIPTION 

or new growth. Here also we must recognize some local 
' irritation' as the immediate cause of cell-proliferation, but 
the new cells produced are in these cases more robust and 
long-lived. Instead of quickly dying by fatty degeneration, 
they grow to a considerable size and develop processes, so as 
to form the fusiform and stellate corpuscles of connective 
tissue. The intercellular matrix also develops into well- 
formed fibres. These cells are also liable to fatty degenera- 
tion, but the process is much more slow, less destructive, 
and more akin to the normal transformation of ordinary con- 
nective into adipose tissue That the two directions 

the morbid change may take are far from mutually exclu- 
sive is shown by the histological characters as well as by the 
clinical features of the disease. For the internal organs the 
condition is all but simple fatty degeneration ; in the macula? 
of the skin there is more, persistent cell-proliferation, and in 
nodules of X. tuberosum the formative process greatly out- 
strips the degenerative." 

The macular form on the eyelids and generative parts has 
to be distinguished from patches of aggregated milium and 
also tiny sebaceous cysts. 

Treatment must be directed to removal of the cause of the 
jaundice, and perhaps, when the patches get painful, as is 
often the case, some local soothing applications may be com- 
forting. Or should the presence of the patches in X. palpe- 
brarum be strongly objected to, Mr. George Lawson's opera- 
tion for their removal may be performed. He pinches the 
diseased portion of skin up, cuts it off with scissors, and 
brings the edges of the wound together with a suture or 
two. The result is eminently satisfactory. 

Xanthelasmoidea is a term which we give to a rare 
form of eruption characterized by the presence of certain 
buff-colored patches that appear in a scattered form in young 
children, and at first sight look like xanthelasma, in small 



OF CUTANEOUS DISEASES. 197 

patches, so far as external features are concerned. Cases of 
the kind have been reported by us in our Atlas of Skin Dis- 
eases, and a plate representing the disease as it attacked the 
leg of a little boy is there given. The disease may be in 
part congenital, or it may appear soon after birth, usually 
when the babe is about two months old. Parents say that 
itchy bumps or places like flea-bites, or even vesicles, first 
appear, and these turn into red, bumpy places, which speed- 
ily assume a buff color. The spots may be scattered sparsely 
or thickly, over parts or the whole body. They are distinct 
the one from the other, and vary in size from a pea to a 
shilling or so. The disease has been generally mistaken for 
syphilis. The spots are readily irritated, and " wheal-like" 
appearances are presented by the patches when freely rub- 
bed ; wheals also are produced by scratching in the healthy 
islets of skin, and this fact, coupled with the presence of the 
pigmentation, has led to the suggestion of the term urticaria 
pigmentosa for the disease ; but the wheal-like aspect is only 
accidental and temporary ; a superaddition, in fact, to the 
real morbid condition, which is clearly an increase of sub- 
stance in the skin, that undergoes no change through a long 
series of years. Nothing is known of the nature of the dis- 
ease histologically, but we hope ere long to publish the re- 
sults of our researches on this point. The disease seems to 
be unaffected by remedies, to produce no disturbance of the 
general health, to undergo little change except that the spots 
become less elevated and paler by age. The chief thing to 
recollect about it is its liability to be mistaken for congenital 
syphilis, an error that may entail considerable risk to the 
child from the adoption of an anti-syphilitic treatment for 
the disease. 

Xeroderma, see Ichthyosis, and Atrophy of the Skin. 

Zoster, see Herpes. 



PAET III. 

CUTANEOUS PHARMACOPOEIA. 



BATHS. 



1. The quantity of water in a bath is estimated at thirty 
gallons, and the tsmperature of the water should be from 
90° to 95° F. 

(a.) Bran and gelatine bath — The quantities to be used 
are — of bran, 2 to 6 ft. ; of gelatine, 1 to 3 lb. ; or of size, 
2 to 4 Jb. Used in all erythematous and itchy and scaly 
diseases. 

(&.) An alkaline bath is made with from ^ij to ^x of bi- 
carbonate of soda, or Bjiij of borax. It is sometimes use- 
ful to add to the bicarbonate of soda some bran liquor, made 
by infusing bran, put into a flannel bag, in a gallon or so of 
hot water. Used in eczema, psoriasis, urticaria, lichen, 
and prurigo, where there is much local irritation. 

(c.) An acid bath is made with ^j of nitric or muriatic 
acid or a mixture of the two (^j of each). Used in chronic 
lichen and prurigo. 

(c?.) A sulphurated potash bath is made by adding ^ij to 
^iv of the drug to each bath. The compound sulphur bath 
of Startin has §ij of sulphur (praecip.), 3J of hyposulphite 
of soda, and ^ss of dilute sulphuric acid with a pint of water. 
Used in itch, chronic eczema, lichen, and psoriasis. 

FUMIGATION. 

2. To administer a medicinal vapor bath, heat is to be 
applied simultaneously to the drug and a small tray of water, 



200 SELECTED FORMULAE AND 

so that steam and vapor of the drug may arise and surround 
the patient's body together. The necessary apparatus may 
be obtained at any instrument makers, or easily be impro- 
vised. A quarter of an hour, and if possible less, should 
usually suffice for the proper action of the bath. The object 
is not to sweat the patient, but to get the skin slightly re- 
laxed at the moment the vaporized metal rises from the 
heated tray below, the object being to secure its deposition 
upon the surface at once. 

For a mercurial bath fifteen to thirty grains of calomel, 
and for a sulphur bath from one to two ounces of sulphur 
should be used. 

CAUSTICS. 

3. Calomel, ^ijss; bisulphide of mercury, 3ij ; arsenious 

acid, 5j- Used in lupus, scrofulous ulcers, and syphilis 

(Dupuytren.) 

4. Caustic potash and water in equal parts. Useful in 
lupus. 

5. Acid nitrate of mercury, made by dissolving 3J of mer- 
cury in ^j of nitric acid (sp. gr. 1.40). Used in neoplas- 
mata, acne indurata, and rosacea, etc. 

6. Chromic acid, 3j > water, 3iv. Used for warts, lupus, 
etc. 

7. Powdered savin, perchloride of mercury, red oxide 

mercury, aa 3j« Used for condylomata and warts (Lang- 

ston Parker.) 

8. Carbolic acid, 1 part; alcohol, 1-4 parts. Used in 
lupus, syphilitic ulcers. 

9. Nitrate of zinc, 1 part ; bread mass, 2 or 8 parts. Used 
in lupus, spread thinly on the part. 

9a. White arsenic, 10 grains; cinnabar, 3 SS > lard, jfss. 
To be used to small portions at a time of lupus erythema- 
todes, and to be re-applied if necessary. 



CUTANEOUS PHARMACOPEIA. 201 

ASTRINGENTS. 

Alum and Zinc. 

10. Alum, gr. xx ; sulphate of zinc, gr. x ; glycerine, 5j ; 
rose-water, ^iv. Used in erythema, intertrigo, eczema. 

Tannic Acid. 

11. Tannic acid, gr. xl ; French vinegar, |§ss ; distilled 
water, ^viiss. Used in seborrhcea — (Neligan.) 

Myrrh and Zinc. 

12. Tincture of myrrh, gtt. xxx ; zinc oxide, gr. xx ; cold 
cream, ^j. Used in prurigo, erythema, lichen — (Neligan.) 

Bismuth and Vaseline. 

13. Trisnitrate of bismuth, 9ij ; solution of subacetate of 
lead, 30 drops ; vaseline, ^j. For intertrigo, eczema, etc. 

Zinc and Glycerine. 

14. Zinc oxide, 3ij ; glycerine, J'j ; solution of subacetate 
of lead, 3iss ; lime-water, £vj to ^viij. Used in the secre- 
tory stage of eczema, in acne, lichen, foul ulcers, impetigo, 
herpes. 

Borax and Glycerine. 

15. Borax, 9j or 3J ; glycerine, 3ij ; rose-water, *viij. 
Used in squamous diseases. 

Acid and Lead. 

16. Dilute hydrochloric or nitric acid, 5 SS 5 l ea( ^ acetate, 
gr. v to x ; glycerine, 3iss ; water, g'vj. Used in eczema 
and lichen. 

Alum. 

17. Alum, 3ij ; infusion of roses, ,^xx. Used in acne, 
pityriasis, and eczema (sine crustis) (Casenave.) 



202 SELECTED FORMULA AND 

SEDATIVES. 

Soda. 

18. Carbonate of soda, 5 SS > conium juice, ^j ; elderflower 
water, 3yj. Used in eczema, lichen, and urticaria, to allay 
itching. 

19. Bicarbonate of soda, 5j > glycerine, 3i ss ; elderflower 
water, ^viss. Used as above, and in acne punctata. 

20. Borax, Jrj ; cherry laurel water, ^j ; elderflower 
water, ^vij. Used in lichen. 

Morphia. 

21. Borax, ^ss ; sulphate of morphia, gr. vj ; rose water, 
ifviij. Used in pruritus vulvce (Meigs.) 

22. Solution of hydrochlorate of morphia, ^iss ; solution 
of potash, 3'j ; glycerine, ^j ; cherry laurel water, ^j ; elder- 
flower water, §xij. Used in pruriginous eruptions. 

Hydrocyanic Acid. 

23. Bichloride of mercury, gr. j ; dilute hydrocyanic acid, 
3j ; emulsion of almonds, ^vj. Used in itching, lichen, and 
prurigo. 

24. Dilute hydrocyanic acid, Jj ; solution of acetate of 
ammonia, §ij ; tincture of digitalis, yi\] ; rose-water, ^v. 
Used in pruritus, prurigo, lichen, and urticaria. 

25. Dilute hydrocyanic acid, 3\j ; borax, 5j ; rose-water, 
^viij. Used in pruritus of old people — (Neligan.) 

Cyanide of Potassium, 

26. Cyanide of potassium, gr. vj ; cochineal, gr. j ; cold 
cream, ,f j. Used in pruritus and urticaria — (Anderson.) 

27. Cyanide of potassium, gr. xv ; water, ^viij. Used 
in pudendal irritation, lichen, and prurigo. It should be 
kept in a dark place (Hardy.) 



CUTANEOUS PHARM ACOPCEIA. 203 

Chloroform. 

28. Carbonate of lead, 3ss; chloroform, r^iv; cold cream, 
^j. Used in pruritus. 

29. Cyanide of potassium, gr. iv ; chloroform, n^viij ; 
glycerine, 5j '■> white wax ointment, 3 V J« Used in pruritus. 
— (Neligan.) 

30. Chloroform, 3j ; glycerine, 3i y — (Duparc.) 

31. Bichloride of mercury, gr. iss ; chloroform, n^xx; 
glycerine, ^ij ; rose-water, 3yj. Used in itching, papular, 
and vesicular diseases, and urticaria (Burgess.) 

Belladonna. 

32. Extract of belladonna, ^ss; dilute hydrocyanic acid, 
^ss ; glycerine, ^j ; water, §xiv. Used in papular and 
phlegmonous affections (Startin.) 

Benzoic Acid. 

33. Benzoic acid, 40 to 60 grains to ^vj of water. Used 
in urticaria to allay itching — (Ringer.) 

Digitalis. 

34. Tincture of digitalis, 3ij to 3iv; glycerine, ^ss; rose- 
water, ^vj. Used in pruritus of a purely neurotic character. 

Lead. 

35. Carbonate of lead, gr. iv; glycerine, 3 j ; simple cerate, 
^j. Used in erythema. 

36. Glycerine, subacetate of lead, and vaseline. (Made 
by Squire, 277 Oxford Street, London.) In intertrigo, ec- 
zema. A convenient application is made by rubbing up from 
half to a drachm of solution of lead, with an ounce of vaseline. 



204 SELECTED FORMULAE AND 

Acetate of Ammonia. 

37. Solution of acetate of ammonia, ^ij ; alcohol, § ss ; 
rose-water, ^iv. Used in lichen — (Burgess.) 

Carbolic Acid. 

38. Liquid carbolic acid, ^ss ; water to Oj. Used to allay 
itching in chronic eczema, or psoriasis. 

Zinc. 

39. Oxide of zinc, 5ij ; solution of lead, 3j ; wine of opium, 
5J » P°PP7 decoction, ^iv. Used in eczema, herpes, etc. 

40. Oxide of zinc, 3j > carbonate of lead, 5j ; spermaceti, 
^j ; olive oil, q. s. To make a soft ointment. Used in se- 
borrhcea, where the skin is inflamed — (Neumann.) 

Camphor. 

41. Camphor, 3ss ; alcohol, q. s. ad solve ; oxide of zinc 
and starch, aa ^j. Used as a powder to allay burning heat 
of eczema (Anderson.) 

42. Camphor, gr. viij ; tincture of conium, 3U '•> simple 
cerate, ^j (Neligan.) 

43. Camphor, £ss or £j. alcohol, § j ; borax, 9*ij ; rose- 
water, ^ viij. Used in 'pruritus, eczema, and the erythemata. 

44. Sulphate of atropine, gr. j ; borax, 3U ; glycerine, 
3iij ; distilled water to §xij. Used to allay pruritus in 
various diseases where skin is not abraded. 

Borax. 

45. Borax, 9ij ; carbonate of soda, 5j '■> glycerine, 3* ss ; 
dilute hydrocyanic acid, ni^xxx ; distilled water, gvj. Used 
in vesicular and sebaceous diseases. 

46. Borax, 9ij ; oxide of zinc, 3j ; solution of subacetate 
of lead, 3\j ; lime-water, ^yj to ^ viij. Used in eczema and 
herpes. 



CUTANEOUS PHARMACOPOEIA. 205 

47. Borax, 5j to 5U 5 glycerine, 5 j ; lard, ^j. Used in 
parasitic diseases, and in eczema, erythema, intertrigo, and 
lichen. 

ABSORBENT POWDERS. 

48 (a). Powdered maize, §iv; oxide of zinc, ^j ; cala- 
mine, ^ss. Used to excoriated surfaces. 

48 (b). Powdered maize, §iv; oxide of zinc, ^j ; orris 
powder, § ss ; essential oil of almonds, gtt. iij. 

49. The white Fuller's earth, or Cimolite (prepared by 
Taylor, Baker Street, London). 

STIMULANTS AND ABSORBENTS. 

50. Alcohol, oil of cade, soft soap, aa ^j : oil of lavender, 
3iss. Used in eczema and psoriasis. — (Anderson.) 

51. Soft soap, §ij ; spirits of wine, ^j ; dissolve, filter, and 
add spirits of lavender, 3'j- Used in seborrhosa — (This is 
the "Kalicreme" of Hebra.) 

Iodide of Starch Paste. 

52. Powdered starch, 1 part ; glycerine, 2 parts ; water, 6 
parts : boil together, and when nearly cold add solution of 
iodine, 1 part. Useful to cleanse and heal foul sores, espe- 
cially such as are syphilitic (Univ. Coll. Pharm.) 

Lead. 

53. Lead plaster, ^ss ; almond oil, ,lss; benzoated oxide 
of zinc ointment, Jij. To be used in eczema as an astrin- 
gent dressing. 

Iodoform. 

54. Iodoform, gr. xxx-lx ; lard, ]§j. Used to dress pain- 
ful bums, ulcers, chancres, and boils. 

18 



206 SELECTED FORMULAE AND 

Mercurial. 

55. Calomel, 5j 5 lard, ^j. Used in herpes, psoriasis, 
and pruritus vulvce. 

56. The oleates of mercury, 5 and 10 per cent. Useful 
in ringworm, syphilis, sycosis, etc. 

57. Green iodide of mercury, gr. ij to gr. xv ; lard, ^j. 
Used in acne (Hardy.) 

58. Calomel, 3j 5 camphor, 3 SS 5 spirits of wine, q. s. ; 
lard, ^j. Used in pruritus of the anal region, and in syph- 
ilitic ulceration. 

59. Bicyanide of mercury, gr. v to gr. x ; lard, §j. Used 
for syphilitic tubercles. 

60. Red oxide of mercury, finely powdered, and ammo- 
niated mercury, aa gr. vj ; lard, §j. (The " Unguentum raer- 
curiale comp.") Used in sebaceous, squamous, ulcerous, 
tubercular, and papular eruptions (Startin.) 

61. Iodine, ^ss ; glycerine, ^ij ; olive oil, ^iijss ; strong 
mercurial ointment, ^ij. (The Linimentum hydrarg. et 
iodini of Startin.) Used in tubercular and cachectic affec- 
tions. 

62. Ammoniated mercury, gr. v ; nitrate of mercury oint- 
ment, gr. xx ; acetate of lead, gr. x ; oxide of zinc, gr. xx ; 
purified palm oil, 5ss ; fresh lard, ^jss. Used in eczema oj 
the head, in children especially. 

63. Nitrate of mercury ointment, Jj ; solution of subace- 
tate of lead, ^\ss ; oxide of zinc, 3j '•> carbolic acid, gr. v ; 
fresh lard, ^j. Used in inflamed or irritable psoriasis. 

Sulphur. 

64. Iodide of sulphur, gr. x to 3j ; lard, 3j« Used in acne. 

65. Milk of sulphur, 3ij ; aether, ^ss ; spirits of wine, 3iij ; 
glycerine 3"j ; rose water £vj. To be dabbed on once or 
twice a day to indolent acne indurata or rosacea, allowed to 
remain a moment or two, and then dried off with linen. 



CUTANEOUS PHARMACOrGEIA. 207 

6Q. Hypochloride of sulphur, 5lj > carbonate of potash, 
gr. x ; lard, ^j ; oil of bitter almonds, gtt. x. Used in acne. 
—(Wilson.) 

67. Sulphur, glycerine, rectified spirits of wine, carbonate 
of potash, sulphuric ether, equal parts by weight. To be 
rubbed on to the part affected with comedo, with friction. 

Tar. 

68. Tar, alcohol, aa ^j. Used in psoriasis chiefly. 

69. Pyroligneous oil of juniper, 3j to ^j ; mutton suet, 
3ss ; lard, ^j. Used in eczema and psoriasis pal maris, etc. 

70. Tar, 3j ; camphor, gr. x ; lard, 3x. Used in pruritus 
and in vesicular and papular diseases (Baume.) 

71. Detergent solution of tar, 3ij to ^j ; glycerine, 5'j » 
rose water to Jviij. Used in chronic scaly, itchy conditions 
(dilute hydrocyanic acid may be added, itlxxx). 

Silver. 

72. Silver nitrate, gr. ij to gr. x ; water, §j. Used in 
eczema and erythemata. 

Bismuth. 

73. Bismuth nitrate, 3lj 5 mercury bichloride, gr. x ; 
spirits of camphor, 5 SS > water, q. s. ad ^xvj. Lotio bis- 
muthi nitratis. Used in sebaceous, pustular, and vesicular 
diseases, and in pityriasis. Use diluted with 1 to 3 parts 
water — ( S tartin.) 

Zinc. 

74. Oxide of zinc, 5\i ; calamine powder, §ss ; glycerine, 
3ij ; rose water, ^ v j- Used in eczema, especially where the 
surface is red and tender. A grain of the bichloride of 
mercury may be added. 

75. Sulphate of zinc, 3 SS ; oxide of zinc, 3j '■> alum, 3j ; 
glycerine, 3\j ; r °se water to ^vj or more. Used in scaly 
stages of eczema, indolent intertrigo, etc. 



208 SELECTED FORMULAE AND 

Hebrews Unguentum Diachylon. 

76. This is made by boiling together olive oil, |xv, and 
litharge, ^iij et 3 v j> to ft good consistence, and adding oil 
of lavender, 5ij« Used in eczema, applied twice a day on 
linen. 

77. Subcarbonate of soda, 3\j ; extract of opium, gr. x ; 
slaked lime, 5j ; liquor plumbi, ^ij. Used for severe itching 
in prurigo (Biett.) 

78. Nitrate of mercury ointment, 30 > camphorated oil, 
glycerine, aa ^ss. Used in psoriasis. 

78 (a). Solution of chlorinated soda, £ss ; carbonate of 
potash, gr. xx ; orange flower water, %x. Used for freckles. 

PLASTERS. 

79. Camphor, 3ss ; black pitch, 3vj ; yellow wax, %ix ; 
red oxide of lead, ^ij ; olive oil, 3jiv. To be melted together 
till a little burned. Used in boils. (JEJmplastrum. fuscum.) 

80. Mercury, %v ; turpentine, 3ij ; yellow wax, Jiij ; lead 
plaster, jfiss. Used in acne rosacea. — (Emplastrum hy- 
drargyri Neumann.) 

81. Mercurial plaster, soap plaster, aa ^j. Used for syphi- 
litic papules, tubercles, and indurations generally. 

82. Ammoniated mercury, 3ss ; soap plaster, ^ss. Used 
in syphilitic excoriations and ulcerations. (Sigmund.) 

83. Red oxide of mercury, 3 SS '■> ammoniated mercury, 
3ss ; soap plaster, ^ij. Used in syphilitic cracks and fis- 
sures about the hand, indurations, etc. 

MIXTURES. 

84. Solution of bichloride of mercury, 5yj ; dilute hydro- 
chloric acid, 3 SS 5 water, ^vj. A sixth part to be taken 
twice a day in syphilis. 

85. Bichloride of mercury, gr. j ; iodide of potassium, 3'j ; 
water, ^iij. A dessertspoonful three times a day. Used in 
acne (Burgess.) 



CUTANEOUS PHARMACOPEIA. 209 

86. Solution of bichloride of mercury, 3 v j 5 iodide of 
potassium, 3j ; compound tincture of iodine, n^xv; water, 
3 viij. A sixth part may be taken twice a day. Used in 
syphilis. 

87. Bichloride of mercury, gr. | to T \ ; arsenious acid, 
gr. gV to ^q ; water, ^ss. For each dose, in chronic syphilis. 

88. Iodide of potassium, 3ss-5iij ; sal volatile, 3iij ; syrup 
of orange-peel, 5 1V ; water to g viij . A sixth part with half 
a tumbler of water twice a day. The dose of iodide of po- 
tassium may be increased gradually still further, if required. 
Used in secondary and tertiary syphilis. 

89. Iodide of potassium, 5ss or more ; potassio-tartrate of 
iron, 5j ; syrup, ^ss ; water, J vj. One-sixth part for a dose, 
in chronic syphilis in anaemic subjects. 

90. Wine of iron, ^jss ; simple syrup, ^ss ; Fowler's so- 
lution, gtt. xlviij ; distilled water, to ^vj. Dose: a table- 
spoonful twice or thrice a day, in psoriasis and other chronic 
skin diseases. 

91. Fowler's solution, rr^lxxx ; iodide of potassium, gr. 
xvj ; iodine, gr. iv ; orange-flower water, ^ij. Dose: a tea- 
spoonful with water three times a day. Used in eczema. — 
(Neligan.) 

92. Cod-liver oil, ^ij ; yelk of one egg; Fowler's solu- 
tion, TTi,lxiv ; syrup, 5ij ; distilled water, q. s. ad Jiv. Dose : 
one teaspoonful three times a day — (Wilson.) 

93. Arseniate of soda, gr. i. to ij ; distilled water, ^ viij. 
Dose : one tablespoonful twice daily. 

94. Hydrochloric solution of arsenic, 3ss ; dilute hydro- 
chloric acid, 5J ; tincture of the chloride of iron, 3iss to 3iij ; 
water, g viij. Dose: a sixth part three times a day. In 
psoriasis and eczema in anaemic subjects. 

95. Sulphate of magnesia, 3"j ; sulphate of iron, gr. xij; 
dilute sulphuric acid, 3ss ; infusion of quassia, q. s. ad J viij. 
Dose : one-sixth part twice daily. Used in acne, eczema, 

18* 



210 SELECTED FORMULAE AND 

impetigo, and ulcerous affections. Quinine may be added if 
desired. 

96. Sulphate of magnesia, 5* v > carbonate of magnesia, 
5j ; tincture of colchicum, n^xxxvj ; oil of peppermint, nijj ; 
water, o y ij« Dose: a sixth part. Used in erythematous, 
papular, and acute forms of disease in gouty subjects. 

97. Bicarbonate of soda, 3"j ; tincture of calumba, %uj ; 
sal volatile, 3iij ; dilute hydrocyanic acid, rr^viij ; syrup of 
ginger, 5iij ; water, ^vj. Dose : a sixth part an hour before 
the two principal meals. Used in skin diseases accompanied 
by dyspepsia. 

98. Acetate of potash, ^j ; acetic acid, 3ss ; spirits of ni- 
trous ether, ^iss ; fluid extract of taraxacum, ^ij. Dose: a 
teaspoonful with water before meals. Used in acne inda- 
rata (Bulkley.) 

99. Iodide of sodium, 3j ; compound decoction of sar- 
saparilla, ^viij. Dose: a sixth part three times a day in 
obstinate syphilitic eruptions, where iodide of potassium 
disagrees or fails. 

100. Turpentine, rectified, 3ss to %\ss ; creasote, n^iij ; 
spirits of rosemary, ni^xl ; water, q. s. ad ^iv. Dose : two 
teaspoonfuls every three hours. Used in purpura (Budd.) 

101. Acid tartrate of potash, %uy, decoction of broom, 
Jfvj. Dose : one-sixth part three times day. Used as a di- 
uretic and aperient in eczema of the legs with oedema. 

102. Acetate of potash, 3iij ; vinegar of squill, 3iij ; sweet 
spirits of nitre, n^xx ; compound decoction of broom, §viij. 
Dose : a sixth part thrice daily. Used as a diuretic, where 
the skin is very hyperaamic and the urine not freely voided. 
Digitalis may be added if desired. 

103. Strychnia, gr. ss-j ; dilute phosphoric acid, 3iij ; tinc- 
ture of orange-peel, ^ss ; infusion of cloves, ^xj. Dose : 
half an ounce three times a day. Used in prurigo and 
lichen. 



CUTANEOUS PHARMACOPOEIA. 211 

PILLS. 

104. Red iodide of mercury, gr. j to ij ; extract of gen- 
tian, 9'ij. Make 12 pills. One pill twice a day. 

105. Bicyanide of mercury, gr. j ; quinine, gr. xx ; extract 
of gentian, gr. xxx. To make 20 pills. One twice a day. 
Used in ordinary syphilitic eruptions. 

106. Arseniate of soda, gr. ij ; water sufficient to dissolve 
it ; guaiacum powder, Jss ; sulphurated mercury, £)j. Muci- 
lage sufficient to make 24 pills. One pill two or three times 
a day. Used in chronic skin diseases. — (Wilson.) 

107. Levigated arsenious acid, gr. v ; powdered acacia, 
5ss ; cinnamon powder, 3iij ; glycerine, enough to make 100 
pills. (Pil. arsenicalis comp.) Dose : one or two a day. 

108. Arsenious acid, gr. j ; quinine, gr. 20-30 ; dried sul- 
phate of iron, or reduced iron, gr. xl-3j ; extract of hop, gr. 
x ; extract of gentian, q. s. To be well mixed and divided 
into 20 or 30 pills. One twice a day after a meal. Used in 
chronic skin diseases with debility. 

109. Quinine, gr. j— ij ; reduced iron, gr. ij ; extract of 
nux vomica, gr. \ ; extract of chamomile, gr. j. To be taken 
twice or thrice a day. 

REMEDIES FOR SCABIES AND PHTHIRIASIS. 

110. Sulphuretted potash, Jvj ; hard soap, ifeij ; oil of 
thyme, 5ij '■> olive oil, Oij. Used in scabies and prurigo. 

111. Olive oil, £ij ; sulphate of potash, 5 XV 5 sulphate of 

soda, 5 XV '■> precipitated sulphur, 3 X « Used in scabies 

(Mollard.) 

112. Sulphur, tar, aa §vj ; soft soap, lard, aa ,fxvj ; chalk, 
§iv. Used in scabies. — (Hebra.) 

113. Lard, ^ij ; sulphur, 3v ; carbonate of potash, water, 
aa 3ij- Used in scabies — (Hardy.) 

114. Sublimed sulphur, 3 SS > ammoniated mercury, gr. v; 
creasote, gtt. iv ; olive oil, 3U ; fresh lard, ^j. Used in sca- 
bies. 



212 SELECTED FORMULAE AND 

115. Olive oil, )§ss; lard, ^ss ; powdered stavesacre, 5»j ; 
Soak the stavesacre in hot oil and mix. Used in phthiriasis. 

116. Quicklime, ^ xv j '■> flowers of sulphur, ^xxxij ; water, 
20 pounds. Boil until 12 pounds remain, and then filter. 
Used in scabies (Vlemingk's Solution.) 

117. Iodide of potassium ointment is very efficacious in 
scabies. 

118. Sulphur ointment, ^ij ; oil of chamomile, gtt. xx. 
Used in scabies. 

119. For phthiriasis the ordinary white precipitate oint- 
ment of the Pharmacopoeia is as good a remedy as any, 
diluted from 5 to 10 times. 

120. Liquid storax, *j '■> lard, ^ij. Melt and strain. 
Used in scabies. — (Anderson.) A little sulphur may be 
added if thought desirable. 

REMEDIES FOR VEGETABLE PARASITIC 
DISEASES. 

121. Bichloride of mercury, gr. x to xx ; elder-flower 
ointment, §j. Used in the early stages of favus and tinea 
tonsurans. 

122. Carbolic acid, 3j '■> glycerine, §ss to Jj. Used in 
tinea tonsurans. Or, the same with rose water, ^ iv, in tinea 
circinata. 

123. Hyposulphite of soda, ^iij; dilute sulphurous acid, 
3ss; water, q. s. ad §xvj. Used in all forms of vegetable 
parasitic disease — (Startin.) 

124. Bichloride of mercury, gr. ij to iv ; alcohol, $\v ; 
chloride of ammonium, 5 SS 5 rose water, q. s. ad ^vj. Used 
in scabies, phthiriasis, and tinea versicolor. 

125. Officinal solution of sulphurous acid, 1 part; water, 
2—4 parts. Used in all the tinece. 

126. Pyroligneous oil of juniper, 3ij to 3iv ; lard, Jiiss. 
Used in tinea. 



CUTANEOUS PHARMACOPEIA. 213 

127. Hyposulphite of soda, 5' v I glycerine, ^j ; distilled 
water, Jvj. Used in pruritus vulvce and tinea versicolor. 

128. Ammoniated mercury, gr. vj-xxx : red oxide of 
mercury, powdered, gr. vj-xxx ; lard, ^j. Used in all forms 
of ringworm — (Startin.) 

129. Strong ammonia liniment, ^ss ; castor oil, ^ss ; 
spirits of turpentine, purified, ^ss ; ammoniated mercury, gr. 
xv. Brush into the scalp with a hard brush until irritation 
is set up. For baldness. 

130. Tincture of cantharides, ^j ; distilled vinegar, Hiss; 
glycerine, 3i ss ; spirits of rosemary, §iss; rose water, ^viij. 
To be well sponged into the scalp night and morning. For 
thinning or loss of hair in the scalp. 

131. Blistering fluid (liniment, cantharides), 3J ; sulphate 
of zinc, gr. xx ; balsam of Peru, 3iss ; powdered galls, 3'j ; 
lard, 3j. For tinea tonsurans. 

132. Subacetate of copper, gr. xxx ; birch oil, 3iij ; lard, 
3j. Same. 

133. Sulphur, tar, tincture of iodine, lard, aa ^j. Same. 

134. Carbolic acid, 3j ; sublimed sulphur, 5"j '■> tincture 
of iodine, 3"j > vaseline (unguentum petrolei) or lard, 3j- 
In tinea tonsurans. 

135. Blistering fluid, 3j ; sulphate of copper, 9ij ; pow- 
dered galls, 3j ; vaseline, ^j. For ringworm. 

136. Iodine, 3j-ij > colorless oil of wood tar, §j. (This 
preparation is sometimes known as " Coster's paste.") 

137. Tincture of iodine, 3 v j 5 iodide of iron, gr. xij ; ter- 
chloride of antimony (liquid P. B.), %lv. This solution 
should be used with care, and should not be used to sore or 
abraded surfaces ; but with this limitation, if painted over a 
limited area in ringworm, say to an inch square at a time, 
and repeated if need be, it is efficacious. An ointment 
made of 5 or 6 grains of the crystallized terchloride of anti- 
mony to the ounce of lard, with or without ammoniated 
mercury, and used freely to obstinate places, often acts well. 



214 DIET IN 



DIET IN SKIN DISEASES. 

There are one or two observations to be made on this sub- 
ject that may be of use in the management of these diseases. 

First A distinction must be made between the diet of 

the private and hospital patient. The latter often only re- 
quires to be well fed up and his disease then speedily goes ; 
the former, on the other hand, often needs to have a check 
put on the quantity and quality of his food, but both need 
due attention to be paid to their excretory functions, that 
they be not sluggish. 

Secondly In young children, skin diseases often arise 

directly from defective alimentation, as in the case of eczema; 
and it is frequently the case that the child, the subject of 
eczema, intertrigo, or psoriasis, has not a sufficient supply of 
milk, either from excessive dilution or otherwise ; or the 
child is being nursed by a weakly mother. 

Thirdly The regulation of the diet, setting aside the 

question of quantity or quality, is, as a rule, needed not so 
much to directly influence the skin disease as certain states 
of the general health, which modify the particular disease 
present ; for instance to meet dyspeptic, gouty, and rheumatic 
conditions especially, but particularly the former ; and the 
mode in which these act prejudicially upon skin diseases has 
been referred to in Part I. of this work. 

In dyspepsia in connection with eczema, acne, psoriasis, 
lichen, or congestion of the face, it is advisable, especially 
if the urine be very acid, to avoid sugar, tea, coffee, alcoho- 
lics, beer, raw vegetable matter, unripe or uncooked fruit, 
veal, pork, seasoned dishes, pastry, cheese, pickles, and the 
coarser kinds of vegetables, but especially all articles whose 
use is followed by heat or flushing of the face, and by flatu- 
lence, or the like. Milk, the common meats, a light kind of 



SKIN DISEASES. 215 

bread, and some very sound light wine should be the diet of 
dyspeptic patients, whose skins are at all in a state of irrita- 
tion. In very many cases the stomach is at fault at the 
outset, and a careful regulation of the diet is of the utmost 
importance as an aid to the other means adopted to correct 
faults in other parts of the system. This implies on the 
part of the practitioner the possession of an accurate knowl- 
edge of the characteristics of the various forms of gastric, 
intestinal, and hepatic functional diseases, which is indeed 
most necessary to a successful dealing with a great number 
of skin troubles. 

In the case of gouty subjects the above remarks apply 
Avith special force. As regards stimulants, a good light 
claret, or whiskey in Vals water, are the best beverages. 

In strumous subjects, the diet should consist of as much 
fatty matter as possible. 

Fourthly In children who suffer from ringworm, it is 

desirable to give as much fatty matter as possible, by means 
of milk, cream, eggs, and fat meat if they can eat it. 

Fifthly In syphilis, the greatest care should be taken to 

avoid anything beyond the most moderate use of stimulants ; 
their abuse in this 4isease is a source of the greatest aggra- 
vation ; otherwise the diet should be nutritious. 

Sixthly — In all cases in which the onset or early stage of 
a skin disease is accompanied by febrile disturbance, how- 
ever slight, or in which the. disease is very hyperasmic, 
stimulants should be avoided, and the plainest and simplest 
diet ordered. In marked cases of this kind, a milk diet for 
a while is often found to be very beneficial. 

Seventhly In some cases in which the skin is very hyper- 

cemic, this condition is much increased by the ingestion of 
food, especially if dyspepsia exists, in consequence of the 
sympathy existing between the stomach and the part of the 
skin affected. This state of things is especially marked in 
such diseases as acne, congestion of the face, and non-para- 



216 DIET IN SKIN DISEASES. 

sitic sycosis. Stimulants must be avoided, except they be 
diluted with some alkaline water : the use of a diet appro- 
priate to the dyspepsia must be rigorously enforced. 

Eighthly It is said that psoriasis requires an ample meat 

diet ; but the patient must be dieted, and not his disease — 
*. e.j the diet should be plain and nutritious, and adapted to 
the constitutional peculiarities of the individual according 
to circumstances. 

Ninthly In all cases where a skin disease has become 

chronic, and where there is debility, the patient should be 
allowed a full, unstimulating diet. 



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HILL (BERKELEY). SYPHILIS AND LOCAL CONTAGIOUS DIS- 
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HILLIER (THOMAS). HAND-BOOK OF SKIN DISEASES. Second 
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HALL (WRS. M.) LIVES OF THE QUEENS OF ENGLAND BEFORE 
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JONES (C. HANDFIELD). CLINICAL OBSERVATIONS ON FUNC- 
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KIRZES (WILLIAM SENHOUSE). A MANUAL OF PHYSIOLOGY. 
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KENNEDY'S MEMOIRS OF THE LIFE OF WILLIAM WIRT. In 
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T EA (HENRY C.) STUDIES IN CHURCH HISTORY. The Rise of 
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LINCOLN (D. F.) ELECTRO-THERAPEUTICS. A Condensed Man- 
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LEISHMAN (WILLIAM). A SYSTEM OF MIDWIFERY. Includ- 
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American, from the Second English Edition. With additions, by 
J. S. Parry, M.D. In one very handsome 8vo. vol. of 800 pages and 
200 illustrations. Cloth, $5 ; leather, $6. {Jtcst issued.) 

LAURENCE (J. Z.) AND MOON (ROBERT C.) A HANDY-BOOK 
OF OPHTHALMIC SURGERY. Second edition, revised by Mr. 
Laurence. With numerous illus. In one 8vo. vol. Cloth, $2 75. 

LEHMANN (C. G.) PHYSIOLOGICAL CHEMISTRY. Translated by 
George F. Day, M. D. With plates, and nearly 200 illustrations. 
In two large 8vo. vols., containing 1200 pages. Cloth, $6. 

A MANUAL OF CHEMICAL PHYSIOLOGY. In one very 

handsome 8vo. vol. of 336 pages. Cloth, $2 25. 

LAWSON (GEORGE). INJURIES OF THE EYE, ORBIT, AND EYE- 
LIDS, with about 100 illustrations. From the last English edition. 
In one handsome 8vo. vol. Cloth, $3 50. 

LUDLOW (J. L.) A MANUAL OF EXAMINATIONS UPON ANA- 
TOMY, PHYSIOLOGY, SURGERY, PRACTICE OF MEDICINE, 
OBSTETRICS, MATERIA MEDICA, CHEMISTRY, PHARMACY, 
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Third edition. In one royal 12mo. vol. of over 800 pages. Cloth, 
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LYNCH (W. F.) A NARRATIVE OF THE UNITED STATES EX- 
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Same Work, condensed edition. One vol. royal 12mo. Cloth, $1. 

LYONS (ROBERT D.) A TREATISE ON FEVER. In one neat 8vo. 
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MEIGS (CHAS. D.). ON THE NATURE, SIGNS, AND TREATMENT 
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MILLER (JAMES). PRINCIPLES OF SURGERY. Fourth American, 
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THE PRACTICE OF SURGERY. Fourth American, from the 

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MULLER (J.) PRINCIPLES OF PHYSICS AND METEOROLOGY. 
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NELIGAN(J.MOORE). AN ATLAS OF CUTANEOUS DISEASES. In 
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handsome octavo vol. of 637 pages, with 182 illustrations and 
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PAVY (F. W.) A TREATISE ON THE FUNCTION OF DIGESTION, 
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PIRRIE (WILLIAM) . THE PRINCIPLES AND PRACTICE OF SUR- 
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STIMSON (LEWIS A.) A MANUAL OF OPERATIVE SURGERY. 
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STUEGES (OCTAVIUS). AN INTRODUCTION TO THE STUDY 
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SMITH (EUSTACE). ON THE WASTING DISEASES OF CHILDREN. 
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SARGENT (F. W.) ON BANDAGING AND OTHER OPERATIONS 
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SMITH (J. LEWIS). A TREATISE ON THE DISEASES OF IN- 
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SHARPEY (WILLIAM) AND QUAIN (JONES AND RICHAED). 
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SKEY (FEEDEEIC C.) OPERATIVE SURGERY. In one 8vo. vol. 
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STILLE (ALFRED). THERAPEUTICS AND MATERIA MEDICA. 
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STILLE (ALFRED) AND MAISCH (JOHN M.) THE NATIONAL 
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SCHOEDLER (FREDERICK) AND MEDLOCK (HENRY). WONDERS 
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and Physiology. Translated from the German by H. Medlock. In 
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OTOKES (W.) LECTURES ON FEVER. In one 8vo. vol. Cloth, $2. 

STRICKLAND (AGNES). LIVES OF THE QUEENS OF HENRY 
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MEMOIRS OF ELIZABETH, SECOND QUEEN REGNANT OF 

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TANNER (THOMAS HAWKES). A MANUAL OF CLINICAL MEDI- 
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ON THE SIGNS AND DISEASES OF PREGNANCY. From 

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TUKE (DANIEL HACK). INFLUENCE OF THE MIND UPON THE 
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TAYLOR (ALFRED S.) MEDICAL JURISPRUDENCE. Seventh 
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ON POISONS IN RELATION TO MEDICINE AND MEDICAL 



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TODD (ROBERT BENTLEY) . CLINICAL LECTURES ON CERTAIN 
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THOMPSON (SIR HENRY). THE PATHOLOGY AND TREATMENT 
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WALSHE (W. H.) PRACTICAL TREATISE ON THE DISEASES 
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Cloth, $3. 

WATSON (THOMAS). LECTURES ON THE PRINCIPLES AND 
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WOHLER'S OUTLINES OF ORGANIC CHEMISTRY. Translated 
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ELLS (J. SOELBERG). A TREATISE ON THE DISEASES OF 
THE EYE. Third edition, revised by the author. In one large and 
handsome octavo vol., with 6 colored plates and many wood-cuts, 
also selections from the test-types of Jaeger and Snellen. {Pre- 
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HAT TO OBSERVE AT THE BEDSIDE AND AFTER DEATH 
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EST (CHARLES). LECTURES ON THE DISEASES PECULIAR 
TO WOMEN. Third American from the Third English edition. In 
one octavo volume of 550 pages. Cloth, $3 75 ; leather, $4 75. 

LECTURES ON THE DISEASES OF INFANCY AND CniLD- 

HOOD. Fifth American from the sixth revised English edition. In 
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ON SOME DISORDERS OF THE NERVOUS SYSTEM IN 

CHILDHOOD. From the London Edition. In one small 12mo. 
volume. Cloth, $1. 

WILLIAMS (CHARLES J. B. and C. T.) PULMONARY CONSUMP- 
TION : ITS NATURE, VARIETIES, AND TREATMENT. In 
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WILSON (ERASMUS). A SYSTEM OF HUMAN ANATOMY. A 
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600 pages. Cloth, $4 ; leather, $5. 

THE STUDENT'S BOOK OF CUTANEOUS MEDICINE. In 

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WINCKEL ON PATHOLOGY AND TREATMENT OF CHILDBED. 
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